Wheeler v. Aetna Life Insurance Co.

Michael Wheeler (plaintiff) participated in an insurance plan provided by Aetna Life Insurance Co. (Aetna) (defendant). Bryce Wheeler (plaintiff), Michael’s son, had autism. Bryce’s medical records indicated that (1) Bryce’s speech development was normal until he was 18 months old, at which time there was a steep drop in his communication that was consistent with the development of many children with autism; (2) Bryce was diagnosed with autism and would need intensive speech and language therapy; (3) after several years, Bryce continued to respond well to speech therapy; (4) pictures and gestures were used to elicit Bryce’s speech, and Bryce’s spontaneous use of speech increased; and (5) ongoing speech therapy would enable Bryce to continue to increase his ability and was important for restoring the loss of function that resulted from brain activity altered by disease. The Aetna insurance plan specified that coverage was not provided for speech therapy except for speech therapy that was expected to restore speech to someone who had lost previously existing speech function as a result of disease or injury. Under the plan, autism was considered to be a disease. Aetna denied coverage of Bryce’s speech therapy. Aetna did not explain why Bryce’s therapy would not qualify for coverage and did not conduct an independent medical examination of Bryce. The Wheelers filed an action, alleging the wrongful denial of benefits by Aetna in violation of the Employment Retirement Income Security Act. Aetna moved for summary judgment.