Justia Antitrust & Trade Regulation Opinion SummariesArticles Posted in Insurance Law
Ben-E-Lect v. Anthem Blue Cross Life and Health Insurance Co.
Ben-E-Lect, a third-party insurance claim administrator, developed a medical expense reimbursement plan; employers could buy a group policy of medical insurance with a high deductible and self-fund to pay for the healthcare expenses employees incurred within the annual deductible or any copay requirement. The practice of employers’ using such plans in conjunction with a high-deductible health plan is called “wrapping.” Ben-E-Lect was the state’s largest third-party administrator for small group employers who wrapped their employee medical policies. Anthem provides fully insured health plans to the California small group employer market. Beginning in 2006, Anthem announced a series of policies that limited wrapping. In 2014, Anthem prohibited wrapping all Anthem plans. Employer groups who used Anthem plans certified they would not wrap Anthem policies, and agents certified they would not advise employers to enter into any employer-sponsored wrapping plan. Ben-E-Lect sued Anthem.The court of appeal affirmed that Anthem’s policy to prohibit wrapping its health insurance products violated the Cartwright Act (Bus. & Prof. Code, 16700); interfered with Ben-E-Lect’s prospective business relationships; and was an illegal, coercive, vertical group boycott under the antitrust rule of reason (Bus. & Prof. Code, 17200), because Anthem told its insurance agents that if they wrapped any Anthem policies they would be subject to termination loss of sales commissions. The court affirmed an award of $7.38 million and an injunction. The trial court considered sufficient evidence of market power and market injury. View "Ben-E-Lect v. Anthem Blue Cross Life and Health Insurance Co." on Justia Law
Sykes v. Blue Cross & Blue Shield of North Carolina
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
Scout, LLC v. Truck Insurance
This case stemmed from Truck Insurance’s refusal to defend its insured, Scout, LLC, in a trademark infringement action brought over Scout’s use of the trademark ROGUE in the advertisement of its restaurant, Gone Rogue Pub. Scout claimed its use of ROGUE constituted an advertising injury that was covered by the insurance it purchased from Truck Insurance. Truck Insurance did not dispute that ordinarily Scout’s advertising injury would be covered and it would accordingly have a duty to defend, but coverage was properly declined in this instance based on a prior publication exclusion found in the policy. The district court granted summary judgment to Truck Insurance after determining that a Facebook post of Scout’s Gone Rogue Pub logo before insurance coverage began triggered the prior publication exclusion, thereby relieving Truck Insurance of the duty to defend Scout. Scout appealed. Finding no reversible error, the Idaho Supreme Court affirmed the district court. View "Scout, LLC v. Truck Insurance" on Justia Law
Lifewatch Services Inc. v. Highmark, Inc.
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
Marshall v. Safeco Insurance Co. of Illinois
In this insurance coverage dispute, the district court erred in concluding that Plaintiff’s claim under the Unfair Trade Practices Act (UTPA) and the Declaratory Judgment Act should be dismissed.Plaintiff was involved in an accident while she was a passenger in a car driven by Kevin Gallivan. Peter Kirwan owned the vehicle, and Safeco Insurance Company insured Kirwan. Mid-Century Insurance Company insured Gallivan. Plaintiff sued Safeco and Mid-Century (collectively, Defendants), and the parties entered into a settlement agreement. Plaintiff subsequently brought this lawsuit against Defendants bringing claims seeking declaratory judgment and violations under the UTPA and alleging that Defendants used the collateral source statute to justify reduction in her damages notwithstanding that the collateral source statute was inapplicable. The district court granted Defendants’ motion to dismiss. The Supreme Court reversed, holding (1) even if Defendants had a reasonable basis to apply the collateral source statute, the court failed to consider the plain language of the statute and whether it was applicable in Plaintiff’s case; and (2) Plaintiff sufficiently pled an independent cause of action under the UTPA to overcome Defendants’ joint motion to dismiss. View "Marshall v. Safeco Insurance Co. of Illinois" on Justia Law
Newman v. Metropolitan Life Insurance Co.
In this action challenging an insurance company’s doubling of Plaintiff’s insurance premium, the Seventh Circuit reversed the district court’s dismissal of Plaintiff’s complaint for failure to state a claim, holding that Plaintiff was entitled to relief on her contract claim and that the allegations Plaintiff raised were enough to permit her to go forward on her other theories.When Plaintiff was sixty-seven years old, she discovered that Metropolitan Life Insurance Company (MetLife) more than doubled her insurance premium. Plaintiff brought this lawsuit against MetLife on behalf of herself and a proposed class, alleging breach of contract, deceptive and unfair business practices, and common-law fraud. The district court granted MetLife’s motion to dismiss for failure to state a claim, concluding that the insurance policy unambiguously permitted MetLife to raise Plaintiff’s premium. The First Circuit disagreed, holding that the allegations raised in the complaint were enough to entitle Plaintiff to prevail on the liability phase of her contract claim and to go forward on her remaining claims. View "Newman v. Metropolitan Life Insurance Co." on Justia Law
Methodist Health Services Corp v. OSF Healthcare System
Methodist and Saint Francis are the two largest hospitals in Peoria, Illinois. Saint Francis is considerably larger and more profitable. Methodist filed suit, charging Saint Francis with violating the Sherman Act by entering into exclusive contracts with insurance companies, covering more than half of all commercially-insured patients in the area. Methodist argued that it could not obtain a sufficiently high volume of patients to enable it to invest in improvements. The Seventh Circuit affirmed summary judgment in favor of Saint Francis, noting that health insurers regard Saint Francis as a “must have” hospital, because it provides certain services that the other hospitals in the area do not provide, such as solid-organ transplants, neonatal intensive care, and a Level 1 trauma center. The contracts are a form of requirements contract; an insurance company may get better rates from a hospital by agreeing to an exclusive contract, which will drive more business to the hospital. The contracts are of fixed duration; when they terminate, the insurance companies are free to contract with other hospitals. Competition-for-the-contract is protected by the antitrust laws and is common. The court noted that none of the other four area hospitals had joined the case and the Department of Justice declined to file a case. View "Methodist Health Services Corp v. OSF Healthcare System" on Justia Law
Shane Group, Inc. v. Blue Cross Blue Shield of Mich.
Blue Cross controls more than 60% of the Michigan commercial health insurance market; its patients are more profitable for hospitals than are patients insured by Medicare or Medicaid. BC enjoys “extraordinary market power.” The Justice Department (DOJ) claimed that BC used that power to require MFN agreements: BC would raise its reimbursement rates for services, if a hospital agreed to charge other commercial insurers rates at least as high as charged to BC. BC obtained MFN agreements with 40 hospitals and MFN-plus agreements with 22 hospital systems. Under MFN-plus, the greater the spread between BC's rates and the minimum rates for other insurers, the higher the rates that BC would pay. Class actions, (consolidated) followed the government’s complaint, alleging damages of more than $13.7 billion, and seeking treble damages under the Sherman Act, 15 U.S.C 15. In 2013, Michigan banned MFN clauses; DOJ dismissed its suit. During discovery in the private actions, plaintiffs hired an antitrust expert, Leitzinger. BC moved to exclude Leitzinger’s report and testimony. Materials relating to that motion and to class certification were filed under seal, although the report does not discuss patient information. BC agreed to pay $30 million, about one-quarter of Leitzinger's estimate, into a settlement fund and not to oppose requests for fees, costs, and named-plaintiff “incentive awards,” within specified limits. After these deductions, $14,661,560 would be allocated among three-to-seven-million class members. Class members who sought to examine the court record or the bases for the settlement found that most key documents were heavily redacted or sealed. The court approved the settlement and denied the objecting class members’ motion to intervene. The Seventh Circuit vacated, stating that the court compounded its error in sealing the documents when it approved the settlement without meaningful scrutiny of its fairness to unnamed class members . View "Shane Group, Inc. v. Blue Cross Blue Shield of Mich." on Justia Law
Mark Ibsen, Inc. v. Caring for Montanans, Inc.
Mark Ibsen, Inc., the owner and operator of the Urgent Care Plus medical clinic in Helena, purchased health insurance coverage for its employees from Blue Cross and Blue Shield of Montana (BCBSMT) through a Chamber of Commerce program. Health Care Corporation (Health Care) subsequently acquired BCBSMT’s health insurance business and changed its name to Caring for Montanans, Inc. (Caring). Less than one year later, Ibsen filed a complaint and class action against Caring and Health Care claiming that they had violated the Unfair Trade Practices Act (UTPA). Health Care filed a motion to dismiss and Caring filed a motion for summary judgment. The district court granted the motions, concluding that the legislature did not provide private citizens with the right to bring a cause of action to enforce the UTPA. The Supreme Court affirmed, holding (1) Ibsen may not maintain a private right of action for violation of Mont. Code Ann. 33-18-208 and -212 of the UTPA; and (2) in the alternative, Ibsen’s claims cannot be sustained as common law claims. View "Mark Ibsen, Inc. v. Caring for Montanans, Inc." on Justia Law
State ex rel. State Farm Mut. Auto. Ins. Co. v. Hon. Jeffrey D. Cramer
William and Sarah Bassett, who were insured by State Farm Mutual Automobile Insurance Company, alleged that State Farm engaged in unfair trade practices with regard to the Bassetts’ assertion of unfair trade practices. The Bassetts based their claim on the assertion that State Farm never properly offered additional uninsured coverage, as State Farm was statutorily required to do. The circuit court granted the Bassetts’ motion to compel answers to three interrogatories seeking the names, addresses and telephone numbers of State Farm insureds in West Virginia who may have experienced difficulties regarding their uninsured motorist coverage. State Farm filed this original proceeding in prohibition asking the Court to prohibit enforcement of its discovery order. The Supreme Court granted relief, as moulded, prohibiting enforcement of the order granting the Bassetts’ motion to compel, concluding that the circuit court erred by failing to bar the disclosure of the names, addresses and telephone numbers of State Farm’s other insureds. View "State ex rel. State Farm Mut. Auto. Ins. Co. v. Hon. Jeffrey D. Cramer" on Justia Law