## Facts

- Michael Wheeler participated in an employer-sponsored health plan insured by Aetna Life Insurance Company (Aetna).
- Michael’s minor son, Bryce Wheeler, was diagnosed with autism.
- Bryce’s medical records reflected that his speech development was normal until about 18 months of age, when his communication dropped sharply in a pattern consistent with many children with autism.
- Providers documented that Bryce would need intensive speech and language therapy and later reported that he continued to respond well to therapy over several years.
- Treatment records described use of pictures and gestures to elicit speech and reported an increase in Bryce’s spontaneous use of speech.
- Providers stated that continued speech therapy would allow Bryce to keep improving and was important to restore function associated with brain activity altered by disease.
- The plan stated that speech therapy was not covered except for speech therapy expected to restore speech to someone who had lost previously existing speech function as a result of disease or injury.
- Under the plan’s terms, autism was treated as a disease.
- Aetna denied coverage for Bryce’s speech therapy under the plan’s speech-therapy limitation.
- Aetna did not provide an explanation for why Bryce’s therapy did not qualify under the plan’s “restore speech” exception and did not conduct an independent medical examination of Bryce.
- The Wheelers sued under ERISA for wrongful denial of benefits, and Aetna moved for summary judgment.

## Issues

1. Whether speech therapy for a child with autism could fall within a plan exception covering speech therapy expected to restore speech to a person who lost previously existing speech function due to disease, where the record showed early normal speech followed by regression.
2. Whether Aetna was entitled to summary judgment on the ERISA benefits claim given the medical record describing the therapy as restorative and Aetna’s denial without a stated plan-based explanation or independent medical examination.

## Decision

- The court denied Aetna’s motion for summary judgment.
- The court found that the administrative record, viewed under the plan language, supported a triable question (or otherwise precluded judgment as a matter of law for Aetna) on whether Bryce had lost previously existing speech function due to a disease (autism) and whether the requested therapy was expected to restore that function.
- The court treated Aetna’s lack of a clear explanation tied to the plan’s restorative-therapy exception, and its failure to obtain an independent medical examination, as factors cutting against summary judgment for Aetna.

## Legal Principles

- An ERISA benefits dispute is governed first by the written terms of the plan; coverage turns on the plan’s definitions, limitations, and exceptions as applied to the administrative record.
- Where a plan excludes speech therapy except when it is expected to restore speech that was previously present and then lost because of disease or injury, evidence of (a) prior speech ability, (b) subsequent loss associated with a covered cause such as disease, and (c) therapy directed at regaining that function can support application of the exception.
- On summary judgment, the moving party must show there is no genuine dispute of material fact and that it is entitled to judgment as a matter of law; record evidence supporting the plan exception can defeat a motion by the insurer/administrator.
- In evaluating a denial of benefits, courts look for a reasoned decision that connects the plan language to the medical record; an unexplained denial and limited medical evaluation may weigh against the administrator’s position in litigation.

## Conclusion

In Wheeler v. Aetna Life Insurance Co., the court denied Aetna’s motion for summary judgment in an ERISA denial-of-benefits case challenging Aetna’s refusal to cover autism-related speech therapy, where the plan covered speech therapy expected to restore previously existing speech lost because of disease, Bryce’s records showed early normal speech followed by regression consistent with autism, providers described therapy as restoring lost function, and Aetna denied coverage without explaining why the restorative-therapy exception did not apply and without obtaining an independent medical examination.


Wheeler v. Aetna Life Insurance Co., 2003 WL 21789029 (2003)