A six-year-old boy diagnosed with an autism spectrum disorder, received applied behavior analysis (ABA), a type of autism related service, in his home. ABA was covered by his family’s insurance policy. His family requested that the insurer cover similar ABA services to be provided at his elementary school. The insurer denied the request, pointing to a place of service exclusion in the policy, which specified that no services would be covered if the care was provided a certain types of locations, including schools. The family exhausted its internal appeals. The dispute was then submitted to an independent external review agency appointed by the Pennsylvania Department of in Insurance. The independent external review agency upheld the denial based on the policies place of service exclusion.
Subsequently, a Pennsylvania law was enacted that requires health insurance policies to provide coverage for the treatment of autism spectrum disorders, such as ABA services.
The boy, through his parents as next friends, filed a complaint in the Philadelphia County Court of Common Pleas. The complaint sought a ruling that the insurance policy place of service exclusion was null and void under the Pennsylvania law that requires health insurance policies to provide coverage for the treatment of autism spectrum disorders. The complaint also sought an order directing the insurer to cover the boy’s medically necessary treatments. The trial court determined that the insurer was required to provide coverage for ABA services.
The Superior Court reversed holding that a statutory appeal was only authorized with regard to a decision disapproving a denial. The court reasoned that the external review agency had approved a denial of coverage, therefore, the trial court lacked jurisdiction.
The Supreme Court of Pennsylvania reversed and remanded. The court held that the trial court lacked appellate jurisdiction to consider the appeal under the statute governing appeals from denials of coverage for autism-spectrum disorders, but the trial court had jurisdiction to consider the action under the statute providing for jurisdiction over an improvident appeal from a determination by a government unit.
The trial court lacked appellate jurisdiction to consider the appeal under the statute governing appeals from denials of coverage for autism-spectrum disorders. The statute provided that an insurer or an insured could appeal from an agency's “disapproval of a denial or partial denial” of coverage. The plain language of the statute could not be judicially rewritten to provide for an appeal from a decision “approving or disapproving” a denial of coverage.
However, the trial court had jurisdiction to consider the action under the statute providing for jurisdiction over an improvident appeal from a determination by a government unit. The external review agency was at least quasi-governmental. The insured's action was an “improvident” appeal only because of an apparent drafting error in the statute providing that appeals of denials of coverage for autism-spectrum disorders could be taken only from “disapprovals” of denials of coverage.
The Supreme Court of Pennsylvania reversed the appellate court’s reversal of the trial court’s determination that the insurer was required to provide coverage, and remanded the action.
See: Burke ex rel. Burke v. Independence Blue Cross, 2014 WL 5545193 (Pa., October 31, 2014) (not designated for publication).