Tappert v. Anthem Blue Cross Blue Shield
Judicial Arbiter Group, Inc.
JAG Case No. 270779 (2007)
Jill and Stephen Tappert (plaintiffs) had a four-year-old daughter, Abby, who had autism. Anthem Blue Cross Blue Shield (Anthem) (defendant) denied coverage of applied-behavior-analysis (ABA) therapy for treatment of Abby’s autism. The Tapperts claimed that the ABA therapy was a covered benefit under Anthem’s insurance policy. Anthem asserted that there was no coverage because autism was not a congenital defect or birth abnormality. The insurance policy’s “Other Outpatient Therapy Provisions” section excluded from coverage therapies for learning disorders, behavioral or personality disorders, and developmental delays. The policy provided that, for insureds up to age five, this exclusion would not apply to therapies for the treatment of congenital defects or birth abnormalities. The policy defined a congenital defect as a defect or anomaly existing before birth. Anthem’s medical policy defined autism as a developmental disorder that affects parts of the brain that control social interaction and communication. In Anthem’s coverage-denial letter, Anthem acknowledged that Abby was entitled to outpatient therapy for congenital defects and birth abnormalities. In reviewing the Tapperts’ appeal of the denial, Anthem’s medical director, Dr. Jones, expressed the opinion that autism met the requirements for therapies for the treatment of congenital defects or birth abnormalities up until age five and that autism was not a developmental disorder. The matter was before the arbiter for issuance of the arbitration award. Anthem claimed that Jones’s opinion was an accommodation to the autism lobby. Dr. MacHaffie, president of the Colorado chapter of the Americas Academy of Pediatrics, testified that, according to five recent peer-reviewed articles, autism was a neurological disorder that was present in some children at birth.
Rule of Law
Holding and Reasoning (Meyer, J.)
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