Justia Insurance Law Opinion Summaries

John and Michelle Strauss challenged the Court of Appeals decision affirming summary dismissal of their action against Premera Blue Cross, which arose out of the denial of coverage for proton beam therapy (PBT) to treat John's prostate cancer. At issue was whether the Strausses established the existence of a genuine issue of material fact regarding PBT's superiority to intensity-modulated radiation therapy (IMRT), thereby demonstrating that proton beam therapy was "medically necessary" within the meaning of their insurance contract. The Washington Supreme Court determined they did, and therefore reversed the Court of Appeals' decision, and remanded for a jury trial on the disputed facts. View "Strauss v. Premera Blue Cross" on Justia Law

In this case concerning civil liability based on insurer conduct affecting chiropractic services, the Supreme Court affirmed the order of the trial court dismissing all claims in this case, relying on and incorporating its reasoning in a companion case, Sykes v. Health Network Solutions, Inc., __ S.E.2d __ (N.C. 2019)(Sykes I), in holding that the decision in Sykes I met the criteria for collateral estoppel.This case was one of two putative class actions alleging that defendant insurers contracted with Health Network Solutions, Inc. (HNS) to provide or restrict insured chiropractic services in violation of state insurance and antitrust laws. Plaintiffs chose to bring this action against insurers separately from their claims against against HNS and its individual owners in Sykes I, but both actions presented essentially the same claims and relied on the same theories. The trial court dismissed Plaintiffs' claims in this case. The Supreme Court affirmed, holding that collateral estoppel barred Plaintiffs from litigating these matters given the Court's resolution of the issues in Sykes I. View "Sykes v. Blue Cross & Blue Shield of North Carolina" on Justia Law

In this insurance dispute involving an insurer withholding payments to a medical service corporation improperly controlled by nonphysicans the Court of Appeals ruled that the trial court did not err in declining to give a charge requiring the jury to find fraudulent intent or conduct "tantamount to fraud" in order to reach a verdict in favor of the insurers.Plaintiff Andrew Carothers, M.D., P.C., a professional service corporation, filed multiple collection actions against insurance carriers seeking to recover unpaid claims of assigned first-party no-fault insurance benefits. The jury found that Defendants had proved that Plaintiff was "fraudulently incorporated" and that Carothers did not engage in the practice of medicine. Plaintiff appealed, arguing that the court erred in failing to give a jury instruction on "the traditional elements of common-law fraud and fraudulent intent. The Appellate Division affirmed. The Court of Appeals affirmed, holding that the court's instructions to the jury were proper. View "Carothers v. Progressive Insurance Co." on Justia Law

Doe is HIV-positive and takes Genvoya to control his condition. Doe's BlueCross health insurance covers Genvoya. After February 2017, BlueCross required Doe to fill the HIV prescription through mail order or by picking it up at certain brick-and-mortar pharmacies. If Doe used BlueCross's specialty pharmacy network, his co-pay for each monthly batch of Genvoya would be $120. If Doe continued to get the medicine at his local pharmacy, he would have to pay the full cost, thousands of dollars per batch. Doe preferred interacting with his regular pharmacists, who knew his medical history and could spot the effects of harmful drug interactions. He also worried that deliveries to his house might compromise his privacy or risk heat damage to the medicine. Doe filed a putative class action, alleging that BlueCross discriminated against HIV-positive beneficiaries in violation of the Affordable Care Act and the Americans with Disabilities Act (ADA), which breached their insurance contract. The district court dismissed. The Sixth Circuit affirmed. The Affordable Care Act prohibits discrimination against the disabled in the provision of federally supported health programs under section 504 of the Rehabilitation Act. BlueCross did not violate the Rehabilitation Act; it did not exclude Doe from participating in the plan or deny him benefits covered by it. Section 504 does not prohibit disparate-impact discrimination. The ADA claim failed because Doe targets BlueCross’s operation of his health care plan, not its control over his pharmacy (a public accommodation). View "Doe v. BlueCross BlueShield of Tennessee, Inc." on Justia Law

The longstanding dispute between UPMC; UPE, a/k/a Highmark Health and Highmark, Inc. (collectively, “Highmark”); and the Commonwealth of Pennsylvania's Office of the Attorney General (“OAG”) is again before the Pennsylvania Supreme Court. This time, the issue centered on the parties’ rights and obligations under a pair of Consent Decrees that, since 2014, governed the relationship between UPMC and Highmark with regard to the provision and financing of certain healthcare services to their respective insurance subscribers. The Consent Decrees were scheduled to terminate on June 30, 2019. Following the Supreme Court's decision in "Shapiro I," on February 7, 2019, OAG filed a four-count petition at Commonwealth Court to Modify Consent Decrees (“Petition”), thus commencing the underlying litigation. OAG argued the Commonwealth Court erred in concluding that Shapiro I controlled this case, and in so doing, misapplied the applicable principles of contract law. Highmark argued the Commonwealth Court erred in imposing a “materiality” limitation upon the Modification Provision, observing that nothing therein precluded modification of “unambiguous” and “material” terms of the Consent Decrees, as the Supreme Court characterized the termination date in Shapiro I. UPMC counters that OAG’s proposed use of the Modification Provision is contrary to the parties’ intent, in that the intent of the Consent Decrees, UPMC contends, was to establish a five-year transition period for UPMC and Highmark to wind down their contractual relationships, and thereby to minimize disturbance to the health care industry and to avoid sudden disruption of health care consumers’ expectations. The Supreme Court agreed with OAG and Highmark that the Commonwealth Court erred in concluding this case was controlled by Shapiro I. Further, the Court determined OAG and Highmark have set forth a plausible construction of the Modification Provision. The Court remanded this matter back to the Commonwealth Court to interpret the contested provision, and to reconsider the question of extension of the Consent Decrees. View "Pennsylvania v. UPMC, et al." on Justia Law

The Ninth Circuit affirmed the district court's dismissal of plaintiffs' claim that their insurer, Blue Shield, violated the Medical Loss Ratio (MLR) provision of the Patient Protection and Affordable Care Act (ACA). The MLR is the ratio between what an insurer pays out in claims for medical services and the revenue it takes in.The panel held that there was no basis in the language, history, intent or spirit of the ACA to narrow the MLR by excluding payments for services rendered by out-of-network physicians. In this case, the MLR was properly calculated under federal law by including the settlement reimbursements for medical services by nonnetwork providers. Therefore, the district court correctly recognized the services were covered by the plan and the payments were made. View "Morris v. California Physicians' Service" on Justia Law

Christopher Floeting alleged a Group Health Cooperative employee repeatedly sexually harassed him while he was seeking medical treatment. He sued Group Health for the unwelcome and offensive sexual conduct under the Washington Law Against Discrimination, which made it unlawful for any person or the person's agency or employee to commit an act of discrimination in any place of public accommodation. The trial court dismissed on summary judgment, pursuant to Group Health's argument the employment discrimination standard applied. The Court of Appeals reversed. Group Health argued the Washington Supreme Court should import workplace sexual harassment doctrines into the public accommodations context, thereby limiting its employer liability. Declining to do so, the Supreme Court affirmed the appellate court. View "Floeting v. Grp. Health Coop." on Justia Law

The Supreme Court denied the defendant hospital’s petition for a writ of mandamus challenging a trial court’s order requiring the hospital to produce information regarding its reimbursement rates from private insurers and public payers for the services provided to the plaintiff, holding that the trial court did not abuse its discretion in compelling production of the information.The plaintiff, who was uninsured, was treated by the hospital, which billed the plaintiff and filed a hospital lien for the cost of its services. The plaintiff sought a declaratory judgment that the hospital’s charges were unreasonable and its lien invalid to the extent it exceeded a reasonable and regular rate for services rendered. The plaintiff served requests for production and interrogatories on the hospital, including information about reimbursement rates from insurers and government payers. The hospital objected to the discovery requests, but the trial court ordered the hospital to produce the information. The hospital then filed a petition for a writ of mandamus, which the court of appeals denied. The Supreme Court affirmed, holding that the requested reimbursement rates were relevant to whether the hospital’s charges to the uninsured plaintiff were reasonable. View "In re North Cypress Medical Center Operating Co., Ltd." on Justia Law

Plaintiff-petitioner Charissa Schultz was injured in a 2015 car accident in which the other driver failed to stop at a stop sign. The other driver’s insurance company settled for its $25,000 policy limit, and Schultz made a demand on her own uninsured/underinsured motorist benefits under her GEICO policy, which also had a $25,000 limit. In April 2017, after months of correspondence and apparent review of an MRI performed on Schultz in April 2015, GEICO offered Schultz its full policy limit, and it did so without requesting that she undergo an independent medical examination (“IME”). Indeed, GEICO’s claim logs reveal that at the time GEICO decided to offer Schultz its policy limits, it “concede[d] peer review wouldn’t be necessary,” indicating an affirmative decision not to request an IME. A few months later, Schultz filed the present lawsuit asserting claims for bad faith breach of an insurance contract and unreasonable delay in the payment of covered benefits. GEICO denied liability, disputing the extent and cause of Schultz’s claimed injuries and asserting that causation surrounding the knee replacement surgeries was “fairly debatable” because Schultz had preexisting arthritis, which GEICO claimed may independently have necessitated her surgeries. To establish its defense, GEICO ordered the IME and the district court granted that request. The Colorado Supreme Court concluded GEICO’s conduct had to be evaluated based on the evidence before it when it made its coverage decision and that, therefore, GEICO was not entitled to create new evidence in order to try to support its earlier coverage decision. The Court also concluded the district court abused its discretion when it ordered Schultz to undergo an IME over three years after the original accident that precipitated this case and a year and a half after GEICO had made the coverage decision at issue. View "Schultz v. GEICO Casualty Company" on Justia Law

LifeWatch is one of the two largest sellers of telemetry monitors, a type of outpatient cardiac monitoring devices used to diagnose and treat heart arrhythmias, which may signal or lead to more serious medical complications. An arrhythmia can be without noticeable symptoms. Other outpatient cardiac monitors also record the electrical activity of a patient’s heart to catch any instance of an arrhythmia but they vary in price, method of data capture, and mechanism by which the data are transmitted for diagnosis. LifeWatch sued the Blue Cross Blue Shield Association and five of its member insurance plan administrators under the Sherman Act, 15 U.S.C. 1, claiming they impermissibly conspired to deny coverage of telemetry monitors as “not medically necessary” or “investigational,” although the medical community, other insurers, and independent arbiters viewed it as befitting the standard of care. The Third Circuit reversed the dismissal of the complaint. LifeWatch plausibly stated a claim and has antitrust standing. That so many sophisticated third parties allegedly view telemetry monitors as medically necessary or meeting the standard of care undercuts Blue Cross’s theory that nearly three dozen Plans independently made the opposite determination for 10 consecutive years. Read in the light most favorable to LifeWatch, the complaint alleges competition among all outpatient cardiac monitors such that they are plausibly within the same product market. LifeWatch has alleged actual anticompetitive effects in the relevant market. View "Lifewatch Services Inc. v. Highmark, Inc." on Justia Law