Blue Cross & Blue Shield Ass'n v. United States

35 Cont. Cas. Fed. 75,688, 17 Cl. Ct. 558, 1989 U.S. Claims LEXIS 130, 1989 WL 76013
CourtUnited States Court of Claims
DecidedJuly 12, 1989
DocketNo. 200-87C
StatusPublished

This text of 35 Cont. Cas. Fed. 75,688 (Blue Cross & Blue Shield Ass'n v. United States) is published on Counsel Stack Legal Research, covering United States Court of Claims primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Blue Cross & Blue Shield Ass'n v. United States, 35 Cont. Cas. Fed. 75,688, 17 Cl. Ct. 558, 1989 U.S. Claims LEXIS 130, 1989 WL 76013 (cc 1989).

Opinion

OPINION

RADER, Judge.

The Blue Cross & Blue Shield Association (plaintiff or the Association), administers health plans in different geographical areas. The Association instituted this action on behalf of Blue Cross and Blue Shield of Atlanta, Georgia (BCBS). BCBS has a contract with the Office of Personnel Management (OPM)1 to provide health insurance benefits to federal employees and retirees in Georgia.

The Association appeals from a decision of the Armed Services Board of Contract Appeals (Board or ASBCA). The Board determined that BCBS improperly charged its OPM contract for expenses attributed to a mandatory statutory reserve (MSR) required by Georgia state law.

The Board based its decision on a two-step analysis. First, the Board interpreted the MSR clause in the OPM contract to contain certain restrictions. Second, the Board found that BCBS failed to comply with those restrictions. Therefore, the Board reasoned, BCBS could not properly charge the contract for ordinary administrative expenses which BCBS considered MSR expenses.

This dispute arose over the legality of some uses of MSR funds. BCBS used MSR funds for salaries, cars, entertainment, and other ordinary administrative expenses. The Government insists that the contract only permits MSR funds to offset underwriting losses. Resolution of this question requires examination of the contract and a lengthy course of conduct between the parties. ASBCA reviewed this evidence and awarded judgment to the Government.

Plaintiff filed a summary judgment motion seeking reversal of the ASBCA decision. Plaintiff argues that the Board decision rests on erroneous conclusions of law. Plaintiff challenges the first step of the Board analysis. Plaintiff contends that the Board erroneously interpreted the contract as restricting use of MSR funds.

Defendant has filed a cross-motion for summary judgment. Defendant contends that the Board’s decisions of fact and law rest on substantial evidence. After oral argument, this court denies plaintiff’s motion and grants defendant’s motion.

FACTS

In 1960, the Association entered into a contract with the Government to provide [560]*560health insurance for active and retired federal employees. The contract, CS 1039, covered one year and provided an annual renewal option for both parties. The parties have exercised that option each year since the contract’s start.2

In 1960, the contract obligated the Government to pay a share of the expenses incurred by local participating plans to satisfy state MSR requirements. Article X of the contract provided for local plans to report MSR payments:

(c) Other charges composed of—
(iv) The amount necessary to satisfy mandatory statutory reserve requirements of participating plans to the extent that such requirements exceed that portion of the risk charge in (iii) above applicable to such plans. To the extent permissible, the applicable portion of such amount shall be held by the participating plan affected for the benefit of this contract.

From 1960 to 1968, the Government paid BCBS its share of MSR expenses without questioning the validity of state MSR standards.3

In January 1968, the Government first investigated the use of funds paid to offset MSR expenses.4 On January 16, 1968, the General Accounting Office (GAO) wrote to Andrew Ruddock, Director, Bureau of Retirement and Insurance at the Civil Service Commission, to raise the possibility of modifying the contract to discontinue MSR payments. The GAO letter also questioned the disposition of MSR funds in the event state requirements changed or the contract ended:

We would also appreciate your views as to whether an amendment to the prime contract with the National Associations to provide for the return of contributions that have been previously paid by the FEP towards the local plans’ statutory reserve requirements, either upon a reduction in the State’s reserve requirements or, in any event, upon the termination of the contract with the National Associations would be unfair or would adversely affect the program operations.

Blue Cross, 85-2 B.C.A. at 90,117 (Finding No. 29).

Mr. Ruddock, in turn, asked Joseph E. Harvey, Vice President of Blue Cross & Blue Shield, to comment on the GAO letter. On March 26, 1968, Mr. Harvey responded:

The purpose of the reserve is, of course, to guarantee solvency of the Plan in the event of adverse underwriting experience irrespective of how or in what part of the Plan’s business the adverse experience may occur.
Since these reserves are required by law and since amounts needed to build and maintain them must be acquired by the Plans from their total business for the benefit of their total business, it follows that sums paid to the Plans for this purpose belong to the Plans, subject only to the restrictions of state law. Thus the [561]*561Federal Government has no title to, interest in, or control over the use and disposition of these reserve funds.

Id. (Finding No. 30). Mr. Harvey’s letter is silent about the use of MSR funds in the event that a state discontinues or reduces reserve requirements.

On February 25, 1970, in a letter to Mr. Ruddock, Mr. Harvey further explained plaintiff’s view of the funds held by BCBS in its MSR:

[Use of the MSR] then depends upon the overall underwriting experience of the Plan rather than the experience of any single group or line of business. In the event of overall adverse underwriting experience, a local Plan will turn first to any unassigned surplus to cover the loss. If such funds are insufficient, the mandatory reserve is used (usually requiring the advance consent of the State Insurance Department). Use of these reserves relates in no way to the particular groups or lines of business that originally contributed them.

Blue Cross, 85-2 B.C.A. at 90,119 (Finding No. 34).

Later, on February 22, 1974, Mr. Harvey discussed the types of underwriting losses that might trigger use of MSR funds:

The controlling aspect of this matter is the extent of the legal obligation of the involved Plans to set aside certain statutory reserves for protection of the financial solvency of the Plans in the event of extraordinary underwriting losses.

Id. at 90,120 (Finding No. 42).

From 1960 until December 1975, Blue Cross of Georgia/Atlanta, Inc. and Blue Shield of Atlanta, Inc., were separate, local plans in the Government-wide service benefit program. Although jointly managed, a different chapter of the Georgia Insurance Code governed each. Therefore, under the applicable Georgia law, Atlanta Blue Shield accumulated a contingency or epidemic reserve. GA Code Ann. § 56-1818.5 The statute permitted Atlanta Blue Shield to stop accumulating funds whenever the reserve equaled the greater of $75,000.00 or 55% of annual premium income. In contrast, Atlanta Blue Cross was not subject to a state reserve requirement.

In December 1975, Atlanta Blue Shield merged into Atlanta Blue Cross. The surviving entity became BCBS.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

L. W. Foster Sportswear Co., Inc. v. The United States
405 F.2d 1285 (Court of Claims, 1969)
Afro-Lecon, Inc. v. The United States
820 F.2d 1198 (Federal Circuit, 1987)
Beta Systems, Inc. v. The United States
838 F.2d 1179 (Federal Circuit, 1988)
Raytheon Co. v. United States
31 Cont. Cas. Fed. 71,309 (Court of Claims, 1983)
Iconco v. United States
32 Cont. Cas. Fed. 72,720 (Court of Claims, 1984)
Tibshraeny Bros. Construction, Inc. v. United States
32 Cont. Cas. Fed. 73,017 (Court of Claims, 1984)
Cherry Hill Sand & Gravel Co. v. United States
33 Cont. Cas. Fed. 74,030 (Court of Claims, 1985)
Blue Cross & Blue Shield Ass'n v. United States
34 Cont. Cas. Fed. 75,408 (Court of Claims, 1987)
Utley-James, Inc. v. United States
34 Cont. Cas. Fed. 75,478 (Court of Claims, 1988)
Merando, Inc. v. United States
475 F.2d 603 (Court of Claims, 1973)
Dale Ingram, Inc. v. United States
475 F.2d 1177 (Court of Claims, 1973)
Thanet Corp. v. United States
591 F.2d 629 (Court of Claims, 1979)

Cite This Page — Counsel Stack

Bluebook (online)
35 Cont. Cas. Fed. 75,688, 17 Cl. Ct. 558, 1989 U.S. Claims LEXIS 130, 1989 WL 76013, Counsel Stack Legal Research, https://law.counselstack.com/opinion/blue-cross-blue-shield-assn-v-united-states-cc-1989.