Pennsylvania Superior Court Holds That Most Insurers Must Pay for Autism Services in School

by Dennis McAndrews, Esq.

Founder and Managing Partner at McAndrews Law Offices, P.C.

In a long awaited ruling, Burke v. Independence Blue Cross, the Pennsylvania Superior Court held on November 13 that major insurers like Independence Blue Cross (IBC) must cover “in school” services for children with autism. When IBC refused to pay for therapy in school, the Burke family brought an action to compel these services for their seven-year-old child with the assistance of the Pennsylvania Health Law Project. The family sought insurance coverage for Applied Behavioral Analysis therapy, which is viewed by most professionals as possessing a solid research–based efficacy and which enhances social acclimation and development.

The statute interpreted by the Superior Court was a Pennsylvania law called Act 62, the “Autism Insurance Law”, which requires large private health insurers and Medical Assistance programs to pay for the diagnoses and treatment of autism for children and adolescents. IBC argued that its insurance policy excluded all services in schools, and since the therapist worked at school, the law had no application to the IBC policy. In 2011, a state trial court disagreed and decided that IBC, like all private insurers subject to Act 62, was legally required to pay for needed services and treatment for autism, including those provided in school regardless of an exclusion clause. IBC appealed this decision, and the Superior Court agreed with the trial court, and held that because Act 62 specifically mandates the provision of autism services, a general exclusion in a policy for school–based services could not control the Act’s specific language and the intent of the legislature to require the provision of necessary services for children with autism. The ruling may be found the following link:

http://www.pacourts.us/assets/opinions/Superior/out/J-A11007-15o%20-%201024350135688889.pdf?cb=1.