Lefler v. United Healthcare of Utah, Inc.

F I L E D
United States Court of Appeals
Tenth Circuit
UNITED STATES COURT OF APPEALS
AUG 14 2003
TENTH CIRCUIT
PATRICK FISHER
Clerk
KATHY LEFLER, RAY JUDD,
MICHAEL TUFT, MATTHEW
SWAINSTON and the class of
similarly situated persons,
No. 01-4228
Plaintiffs/Appellants, (Utah)
(D. C. No. 2:95-CV-1109-S)
v.
UNITED HEALTHCARE OF UTAH,
INC., a Utah corporation, formerly
known as Physicians Health Plan of
Utah,,
Defendant/Appellee.
ORDER AND JUDGMENT *
Before TACHA, Chief Circuit Judge, HARTZ and O’BRIEN, Circuit Judges.
In 1995, Ms. Kathy Lefler and other plaintiffs (Class) brought this class
action against United HealthCare of Utah, Inc. (United), a health maintenance
organization, under the Employee Retirement Income Security Act of 1974
*
This order and judgment is not binding precedent except under the
doctrines of law of the case, res judicata and collateral estoppel. The court
generally disfavors the citation of orders and judgments; nevertheless, an order
and judgment may be cited under the terms and conditions of 10th Cir. R. 36.3.
(ERISA) 2, seeking to recover benefits due under an employee welfare benefit
plan, 29 U.S.C. §1132(a)(1)(B) 3, and for other equitable relief, 29 U.S.C.
§1132(a)(3). The Class challenged United’s method of calculating co-payments,
which it alleged violated the terms of the plan because it effectively increased
their percentage contribution to the actual cost of covered services. Concluding
United’s practice resulted from a reasonable interpretation of the benefit plan, the
district court granted summary judgment to United and denied summary judgment
for the Class. Exercising jurisdiction under 28 U.S.C. §1291 (2002), we affirm.
Factual Background
United is licensed in Utah, but owned by parent United HealthCare Services,
Inc., located in Minnesota. During the class period, 1992 to 1995, United
provided health insurance to approximately 100,000 people in Utah through
employer-sponsored health insurance plans governed by ERISA. In most
instances, employees contributed to the premiums. United was a fiduciary 4 under
2
29 U.S.C. §§1001 through 1461 (1995).
3
The Class consists of employees and dependents with average claims
between $100.00 and $200.00. The Class abandoned its claims for declaratory
and injunctive relief since United changed its challenged practice in 1995. This
lawsuit is thus limited to what minimal individual refunds might be available to
members of the Class. Of course, attorneys fees and costs are also at stake.
4
“[A] person is a fiduciary with respect to a plan to the extent (i) he
exercises any discretionary authority or discretionary control respecting
management of such plan or exercises any authority or control respecting
management or disposition of its assets, . . . or (iii) he has any discretionary
-2-
the plans. Policy terms were stated in a Certificate of Coverage, which along with
its Schedule of Benefits constituted the plan documents for an employer unit. The
Schedule of Benefits varied according to the coverage elected by a particular unit,
but provided for beneficiary co-payments stated as a percentage of eligible
expenses, usually ten or twenty percent.
The participants were required to obtain health services from “participating
providers” with whom United had negotiated contracts. Among other things, those
providers charged United discounted rates. United calculated participant co-
payments based upon full billed charges but paid providers against the discounted
rates. 5 That is the source of the Class’ dissatisfaction. As a consequence of
United’s practice, the Class members claim to have unknowingly and
inappropriately paid a greater percentage of the actual cost of the service than the
co-payment percentage stated in their Schedule of Benefits.
In none of the plan documents did United promise to pay the difference
authority or discretionary responsibility in the administration of such plan.” 29
U.S.C. §1002(21)(A).
5
For example, if a health service was billed at $1,000.00 and the plan
required a twenty percent co-payment, a participant would pay $200.00 directly to
the provider. And, if United had arranged a discounted fee of $800.00 for the
service, it would pay only $600.00. As a result, the participant’s actual share
would be twenty-five percent, not twenty percent.
-3-
between the co-payment and the amount billed, or any other specified amount. 6
United did not disclose in the plan documents or in any Explanation of Benefits
provided to the Class members that it had negotiated a discount from participating
providers’ regular, full billed charges. Nor did it reveal the amount it paid to
participating providers (the difference between the co-payment and the discounted
rate). The Certificate of Coverage only described a participating provider as one
with whom United had entered into “a written agreement . . . to provide health
services to covered persons.” (R. at 246).
During the Class period, Utah Code Ann. §31A-26-301.5(2)(c) provided:
“[T]he insurer shall notify the insured of payment and the amount of payment made
to the provider.” 7 On its Explanation of Benefits, United only indicated the amount
it paid to a provider was a “contracted fee.” (R. at 486-87). But occasionally a bill
from a participating provider to a participant would clearly state the amount paid by
United, and the co-payment methodology employed. There were common instances
where a co-payment was the only amount paid for the service because of United’s
negotiated discounted fee with the provider.
Borrowing established Medicare practice, United routinely considered the
6
This plan contrasts with conventional indemnity insurance in which the
insurer agrees to pay all covered charges exceeding the participant’s co-payment.
7
Legislative history establishes the purpose of this language was to pass
through to an insured discount rates negotiated between a health service provider
and a payor-insurer.
-4-
full billed charges submitted by participating providers to be “reasonable and
customary charges” under the plan. In support of this practice, it filed an
affidavit from Dr. William Cleverly, an expert in the health care industry.
According to Dr. Cleverly, hospitals submit a standard charge for services to
insurers and other payors on a form used industry-wide and generated by the
federal Health Care Financing Administration (HCFA), which administers the
Medicare program. But those standard charges are typically discounted in
accordance with individual contracts negotiated between payors and service
providers. Under Medicare, for example, the patient’s percentage co-payment is
calculated against the full billed charge, even though Medicare pays the hospital a
reduced fee set by government regulation and tied to a provider’s reasonable cost.
United also submitted the affidavit of Terry Cameron, a consultant for
health care providers, who stated individual physicians also submit standard
charges on a widely used HCFA form. Like hospital fees, these charges are based
on a uniform schedule even though the amounts the physicians actually receive
often vary according to the payor. According to Mr. Cameron, the standard
charges are fed into databanks maintained by the Health Insurance Association of
America (HIAA) and others, and used to compile information on reasonable and
customary charges around the country. Significantly, in her deposition, Class
expert Mary Covington, an insurance claims auditor, pointed out that United
-5-
considers any charge at or below the eighty to eighty-fifth percentile of the HIAA
schedules to be “reasonable and customary.” Charges above the eighty to eighty-
fifth percentile were considered ineligible.
United’s evidence revealed that co-payment methods were routinely
explained to units enrolled in the plan and to the Class members, usually when
employers were comparing different insurance plans in the market or during
enrollment meetings with employees. 8 The declared advantage of this practice
was lower premiums since United’s premiums were experience-rated, that is,
directly tied to actual expenditures for health care service. 9 The named Class
members denied knowledge of this practice. But, in affidavits submitted by
United, two participants who were not named members of the Class stated they
were aware of United’s co-payment methodology. Each considered United’s
practice an advantage since it lowered premium rates and slowed rate increases.
The Minnesota Department of Health, an agency with jurisdiction over United’s
parent company, had approved an identical co-payment methodology. Prior to
1992, the Department’s rules limited co-payments to twenty-five percent of the
provider’s “costs or charges.” To dispel confusion between “cost” and “charge,”
8
Affidavits of independent insurance agents Donald Sparks.
9
Mr. Sparks’s market research showed that if United was to calculate co-
payment percentages against a discounted fee it would result in an increase of one
percent in cost of premiums for an employer.
-6-
a 1992 amendment to the rules deleted the word “cost” and explicitly limited the
co-payment to twenty-five percent of the “provider’s charge,” defined as “the fees
charged by the provider which do not exceed the fees that provider would charge
any other person . . . .” Minn. R. 4685.0801 (1999). 10 However, there was no
evidence any other insurer in Utah calculated co-payment percentages as United
did during the class period.
District Court Decision Under Review
In addition to its claims under 29 U.S.C. §1132(a)(1)(B), 11 the Class
alleged United breached its fiduciary responsibility. It sought, under 29 U.S.C.
§1132(a)(3), 12 to impose a constructive trust for monies it contends were
improperly held as a result of United’s co-payment methodology.
10
In spite of protests from organizations taking a position identical to that
of the Class in this case, an administrative law judge recommending adoption of
the amendment wrote, “[t]he proposed rules are intended to clarify that the
provider’s charge is a proper basis for calculating the co-payment.” Minn. Office
of Administrative Hearings, Report of Administrative Law Judge, 11-0900-6030-
1, p.5 (1992), 1992 WL 811246, p.4.
11
“A civil action may be brought – (1) by a participant or beneficiary . . .
(B) to recover benefits due to him under the terms of his plan, to enforce his
rights under the terms of the plan, or to clarify his rights to future benefits under
the terms of the plan.” 29 U.S.C. §1132(a)(1)(B).
12
“A civil action may be brought – (3) by a participant, beneficiary, or
fiduciary (A) to enjoin any act or practice which violates any provision of this
subchapter or the terms of the plan, or (B) to obtain other appropriate equitable
relief (i) to redress such violations or (ii) to enforce any provisions of this
subchapter or the terms of the plan. 29 U.S.C. §1132(a)(3).
-7-
With respect to the §1132(a)(1)(B) claim, the district court found both the
Class’s interpretation of the plan language (co-payment percentages should be
applied against a provider’s discounted rate) and United’s interpretation of the
same language (co-payment percentages should be applied against the full billed
charge) to be reasonable. Because the policy language was susceptible to two
reasonable interpretations, the district court concluded it was ambiguous.
However, since United enjoyed the prerogative to construe policy terms and
conditions, and since its construction was not arbitrary or capricious, the district
court granted summary judgment to United. Since the Class presented an
arguable § 1132(a)(1)(B) claim, the district court, relying on Varity Corp. v.
Howe, 516 U.S. 489 (1996), concluded its § 1132(a)(3) claims were foreclosed
and dismissed them.
Standard of Review
We review de novo the district court’s grant of summary judgment under
Fed. R. Civ. P. 56(c), viewing the evidence and reasonable inferences to be drawn
from it in the light most favorable to the nonmoving party. Simms v. Okla. ex rel.
Dep’t of Mental Health & Substance Abuse Servs., 165 F.3d 1321, 1326 (10th Cir.
1999), cert. denied 528 U.S. 815 (1999). However, there is a nuance to the
standard of review as it applies to a §1132(a)(1)(B) claim. It concerns United’s
exclusive right, under its Certificate of Coverage, to construe the terms and
-8-
conditions of the plan. The Supreme Court has held “a denial of benefits
challenged under §1132(a)(1)(B) is to be reviewed under a de novo standard
unless the benefit plan gives the administrator or fiduciary discretionary authority
to determine eligibility for benefits or to construe the terms of the plan.”
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). In such an
instance, the exercise of fiduciary discretion is reviewed under an arbitrary and
capricious standard. Chambers v. Family Health Plan Corp., 100 F.3d 818, 825
(10th Cir. 1996). But, if the fiduciary has a conflict of interest, 13 a court applying
the standard “must decrease the level of deference given to the conflicted
[fiduciary’s] decision in proportion to the seriousness of the conflict.” Id.; see
also Firestone, 489 U.S. at 115. The conflict is weighed as a factor in
determining the level of deference, which “will be decreased on a sliding scale in
proportion to the extent of conflict present, recognizing the arbitrary and
capricious standard is inherently flexible.” McGraw v. Prudential Ins. Co. of
America, 137 F.3d 1253, 1258 (10th Cir. 1998). If the conflict of interest is so
strong as to eliminate any deference, we will independently construe the plan
according to ordinary rules of contract interpretation. Otherwise, we will uphold
the fiduciary’s interpretation if it is reasonable.
13
“[A] fiduciary shall discharge his duties with respect to a plan solely in
the interest of the participants and beneficiaries . . . .” 29 U.S.C. §1104(a)(1).
-9-
Like the district court, we conclude United is a conflicted fiduciary.
“[W]hen an insurance company serves as ERISA fiduciary to a plan composed
solely of a policy or contract issued by that company, it is exercising discretion
over a situation for which it incurs direct, immediate expense as a result of
benefit determinations favorable to plan participants.” Pitman v. Blue Cross &
Blue Shield of Okla., 217 F.3d 1291, 1296 (10th Cir. 2000) (quotation marks and
citation omitted). As well, savings United realized from its challenged practice
contributed to the vitality of its business and its competitive position in the
insurance industry. 14 Id.While we recognize United’s conflict of interest, it is not so strong as to
eliminate deference to its interpretation of the plan if that interpretation is
otherwise reasonable. Its challenged practice, being systemic and not arbitrarily
or capriciously applied to individual plan participants or beneficiaries, diminishes
the level of its conflict. To be sure, the plan design purposefully results in cost
14
United argues any savings it realized in its co-payment methodology were
passed on to its enrolled units in the form of lower premiums, since premiums
were experience-rated. While this may have benefitted plan participants and
beneficiaries when employees contributed to premiums, they did not always do so.
Nevertheless, United argues premium savings realized by enrolled units positively
affected all plan participants and beneficiaries by enabling the enrolled unit to
maintain broad coverage and/or forestall rate increases. In this way, United
argues, lower premiums contributed to the overall health of the employer unit,
indirectly benefitting employees. While plausible, these arguments do not
diminish the market advantage enjoyed by United as a result of its co-payment
methodology.
-10-
shifting to the Class members who access health services by requiring them to pay
a greater portion of the actual cost of those services. But plan design is immune
from judicial review. Jones v. Kodak Med. Assistance Plan, 169 F.3d 1287, 1292
(10th Cir. 1999). As we consider the reasonableness of United’s interpretation of
the plan, we are reminded a fiduciary’s interpretive decision
need not be the only logical one nor even the best one.
It need only be sufficiently supported by facts within
[its] knowledge to counter a claim that it was arbitrary
or capricious. The decision will be upheld unless it is
not grounded on any reasonable basis. The reviewing
court need only assure that the [fiduciary’s] decision
fall [s] somewhere on a continuum of
reasonableness–even if on the low end.
Kimber v. Thiokol Corp., 196 F.3d 1092, 1098 (10th Cir. 1999) (quotation marks
and citations omitted) (emphasis in the original). Significantly, it is of no
moment that the Class’s interpretation of the Certificate language is also
reasonable. We test only to determine if United’s interpretation is reasonable. As
stated in Kimber, “[d]eferential review does not involve a construction of the
terms of the plan; it involves a more abstract inquiry–the construction of someone
else’s construction.” Id. at 1100 (quoting Morton v. Smith, 91 F.3d 867, 871 n.1
(7th Cir. 1996) (citations omitted)).
-11-
Discussion
§1132(a)(1)(B) Claim
With these principles in mind, we consider the reasonableness of United’s
interpretation of the ambiguous language. 15 Applying the appropriate standard of
review, the district court concluded United’s interpretation was reasonable and
sustained by its evidence. We agree.
The Class first argues since co-payment is against eligible expense only
there must perforce be some portion of an expense which United considered
ineligible. While it is thus far correct, it further asserts the ineligible portion of a
claim is the spread between the full billed charge and the discounted fee with the
provider, especially since the provider is prohibited by agreement with United and
by Utah statute from collecting this amount from the class member. As a result,
claims the Class, the eligible expense against which the co-payment should be
applied is the discounted fee. This argument is strained.
A straightforward approach to determining “eligible expense” is more
reasonable. “Eligible expenses” under the policy are defined as “reasonable and
15
To the district court, the Class argued the terms of the plan were
ambiguous. On appeal, it continues that argument but adds an alternative. It now
claims the plan terms are not ambiguous and should be read in its favor. Even if
the alternative argument has merit, we decline to consider it since it is a theory
not presented to the district court. Tele-Communications, Inc. v. Commissioner of
Internal Revenue, 104 F.3d 1229, 1233 (10th Cir. 1997).
-12-
customary charges 16 for health services.” (R. at 244). Since covered “health
services” 17 include only those deemed “medically necessary,” 18 when presented
with a claim United must apply a two-step test for eligibility. First, is the service
“medically necessary?” If not, the service charge is an ineligible expense.
Second, is the charge presented for the service “reasonable and customary?” If
not, it is ineligible. Reasonable and customary charges for medically necessary
services are thus eligible expenses and in turn determine the co-payment.
The Class next takes issue with United’s interpretation of “reasonable and
customary charges” under the plan. It argues the Certificate language referring to
reasonable and customary charges “incurred,” means those costs incurred by
United, and since the cost incurred by United is based on the discounted fee it is
this sum against which a class member’s co-payment percentage ought to be
16
“‘Reasonable and Customary Charges’ - fees for Covered Health Services
and supplies which, in PLAN’s judgment, are representative of the average and
prevailing charge for the same Health Service in the same or similar geographic
communities where the Health Services are rendered and which do not exceed the
fees that the provider would charge any other payor for the same services.” (R. at
247) (emphasis added).
17
“‘Health Services’ - the health care services and supplies Covered under
the Policy, except to the extent that such health care services and supplies are
limited or excluded under the Policy.” (R. at 245).
18
“‘Medically Necessary’ - those Health Services which are determined by
PLAN to be necessary to meet the basic health needs of an individual.
Determination of Medical Necessity is done on a case-by-case basis and considers
several factors including, but not limited to, the standards of the medical
community.” (Id.)
-13-
applied. This is, again, a strained reading of the Certificate. “Co-payment” is
defined as the class member’s responsibility for “health services provided.” (R.
at 243). Health services are provided to the Class members, not United.
Therefore the charge for the service is incurred by the Class member, not United.
The Class also claims United’s interpretation of the phrase “reasonable and
customary charges” is unreasonable because United exercised no “judgment,” as
the Certificate required, as to whether the full billed charge was “representative
of the average and prevailing charge for the same health service in the same or
similar geographic communities where the health services are rendered and which
do not exceed the fees that the provider would charge any other payor for the
same services.” (R. at 247). According to the Class, United’s only exercise of
judgment was in negotiating the discount rate, and thus the discount rate
constitutes the “reasonable and customary charge.” However, the evidence from
the Class’s own witness, Mary Covington, is contrary. United routinely
considered any charge at or below the eighty to eighty-fifth percentile of the
HIAA schedules to be “reasonable and customary.” That is a rational exercise of
judgment and not unreasonable since the practice mirrored Medicare methodology
and was explicitly approved by the Minnesota Department of Health.
Lastly in that vein, the Class argues the full billed charge is not a
“reasonable and customary charge” because it exceeds “the fees that the provider
-14-
would charge any other payor for the same services.” As an example of such a
lower fee, the Class again points to the discount rate which United negotiated
with its participating providers. This argument breaks down if in fairness we
undertake to compare discount rates other payors might have negotiated with the
same providers, to see if those rates are lower than United’s rates. The Class’s
suggested interpretation of “reasonable and customary charge” demands this
comparison. As the district court ably pointed out, it is impossible to compare
other payor-provider negotiated rates because of the proprietary and confidential
nature of such competitor agreements. In the absence of this information, the
Class could never be assured United’s negotiated rate did not exceed another
insurer’s negotiated rate. Since the Class’s interpretation of the Certificate,
offered to rebut the reasonableness of United’s interpretation, would result in
impossibility of contract performance due to the inability to compare other
negotiated rates, the district court rightly favored United’s position.
Moving to a new but related topic, the Class claims United violated Utah
law requiring an insurer to inform a claimant as to the amount it paid the
provider. That violation, the Class argues, makes United’s co-payment
methodology impermissible. 19 This argument was not presented to the district
19
The Class also argues violation of Utah law renders United’s methodology
unreasonable. This argument is not persuasive because if United strictly complied
with the statute the Class would, at most, have been explicitly put on notice of
-15-
court [on the Class’s benefit recovery claim under §1132(a)(1)(B)] and we will
therefore not consider it on appeal. Tele-Communications, Inc. v. Commissioner
of Internal Revenue, 104 F.3d 1229, 1233 (10th Cir. 1997). Nor will we consider
the related theory, first presented on appeal by the Class in its Reply Brief, that
the doctrine of promissory estoppel under Utah law provides remedial relief. Id.For the same reason, we will not consider the Class’s argument that the policy
incorporated ERISA, and therefore fiduciary obligations set out in ERISA are
plan terms subject to enforcement under §1132(a)(1)(B). Id.
Finally, the Class urges application of the doctrine of contra proferentem to
construe the ambiguous language of the plan against the drafter, United. The
district court declined to do this, either on the basis of state or federal common
law, on the grounds of ERISA pre-emption. Were it not for the fact the plan
confers sole and exclusive discretion upon United to construe its terms, albeit
reasonably and subject to increased scrutiny in the case of a conflict of interest,
contra proferentem might apply. But the doctrine is plainly inapposite where a
reviewing court is determining the reasonableness of the construction of the
contract by one of the parties to it instead of construing the language of the
contract itself. “[W]hen a plan [fiduciary] has discretion to interpret the plan
United’s co-payment methodology, which begs the question presented here: the
reasonableness of the methodology itself.
-16-
and the standard of review is arbitrary and capricious, the doctrine of contra
proferentem is inapplicable.” Kimber, 196 F.3d at 1100.
We conclude United’s interpretation of the Certificate language was a
reasonable one. Considering a health service provider’s full billed charge to be
“reasonable and customary” harmonizes well with Medicare practice, an identical
procedure explicitly approved by state regulators in Minnesota, and with the
Certificate requirement the charge of the provider cannot exceed charges to any
other payor for like services.
§1132(a)(3) Claim
The Class sought equitable relief under 29 U.S.C. §1132(a)(3), claiming
United, as a 29 U.S.C. §1002(21)(A) fiduciary, breached its fiduciary duty by
failing to inform the class of its discounting practice 20and improperly denying, de
facto, benefits under the plan. The Class also argues the plan, by its terms,
incorporated Utah law, specifically Utah Code Ann. §31A-26-301.5, requiring
detailed payment notification to an insured. The argument continues – since
United only vaguely described its practice, it violated Utah law and, a fortiori, the
“A summary plan description of any employee benefit plan shall be
20
furnished to participants and beneficiaries . . . . The summary plan description . . .
shall be written in a manner calculated to be understood by the average plan
participant, and shall be sufficiently accurate and comprehensive to reasonably
apprise such participants and beneficiaries of their rights and obligations under
the plan.” 29 U.S.C. §1022(a).
-17-
plan itself.
We agree with the district court that consideration of a claim under 29
U.S.C. 1132(a)(3) is improper when the Class, as here, states a cognizable claim
under 29 U.S.C. §1132(a)(1)(B), a provision which provides adequate relief for
alleged class injury. “[W]e should expect that where Congress elsewhere provided
adequate relief for a beneficiary’s injury, there will likely be no need for further
equitable relief, in which case such relief normally would not be ‘appropriate’.”
Varity, 516 U.S. at 515. Dismissal of the §1132(a)(3) claim was proper as a matter
of law.
Conclusion
For the reasons given, we AFFIRM the judgment of the district court.
Entered by the Court:
TERRENCE L. O’BRIEN
United States Circuit Judge
-18-