In a 4-1 decision in Burke v. Independence Blue Cross issued Thursday, the justices determined that, although the Autism Insurance Act, or Act 62, was ambiguous, the General Assembly did not intend to allow carriers to bar site-specific coverage for autism-related services. The ruling affirmed a decision from the state Superior Court.
“Ultimately, we simply do not believe that the legislature intended to permit insurers to exclude coverage in the sensory-laden educational environment where children spend large portions of their days, or to require families to litigate the issue of medical necessity discretely in individual cases to secure such location-specific coverage for the treatment,” Pennsylvania Supreme Court Chief Justice Thomas Saylor, who wrote the 22-page majority opinion, said.
Justice Sallie Mundy issued a dissent, saying the law clearly allows carriers to use general exclusions.
Pennsylvania Health Law Project attorney David Gates, who represented the plaintiff, said the ruling allows for more access of coverage for environmental-specific treatment.
“This will really provide an extra tool for familiar to access ABA, or applied behavior analysis, which has been proven to be the most effective intervention for children and youth on the autism spectrum,” he said. “I think that this is really consistent with the intent of the legislature.”
Lamb McErlane attorney Maureen McBride represented Independence Blue Cross. A spokeswoman for Independence Blue Cross said the company had just received the court’s opinion and was reviewing it.
The case involves Anthony Burke, who was 6 years old in August 2009, when Magellan Health Services, Independence Blue Cross’ administrator for mental health coverage, denied his request for behavioral analysis services at his elementary school, according to court documents. Magellan pointed to a provision in Burke’s policy that said no benefits would be provided for in-school care.
On Jan. 1, 2010, Act 62 came into effect, providing that insurance policies should cover individuals for autism spectrum disorders. Burke and his father claimed Act 62 required Independence Blue Cross to cover in-school services between that date and July 1, 2010, when the father switched to a self-funded policy not subject to Act 62.
On appeal to the Supreme Court, Blue Cross contended that the act only requires that carriers no longer use the experimental nature of treatments for autism spectrum disorders as a basis for denying coverage, and that the carrier expand the number of credentialed providers.
Saylor, however, said the law was ambiguous and that its allowance for general exclusions conflicted with its central requirement that carriers provide coverage for treatment of autism spectrum disorders. When it came to allowing for “other general exclusions,” Saylor said he took that to mean the law allowed for exclusions that are not targeted at autism-related services, or would go against the mandatory coverage.
“The General Assembly sought to aid autistic children and youth and their families—and to alleviate the need for them to resort to governmental assistance—by tasking private insurers with shouldering, at least in large measure, the financial burden of medically necessary treatments for the condition,” Saylor said. “Accordingly, we agree that the legislature intended to permit only general exclusions that would not substantially undermine the mandatory coverage requirement.”
Max Mitchell can be contacted at 215-557-2354 or email@example.com. Follow him on Twitter @MMitchellTLI.