BLUE CROSS & BLUE SHIELD OF MICH. v. Insurance Comm'r

270 N.W.2d 845, 403 Mich. 399, 1978 Mich. LEXIS 351
CourtMichigan Supreme Court
DecidedOctober 2, 1978
Docket59320, (Calendar No. 2)
StatusPublished
Cited by29 cases

This text of 270 N.W.2d 845 (BLUE CROSS & BLUE SHIELD OF MICH. v. Insurance Comm'r) is published on Counsel Stack Legal Research, covering Michigan Supreme Court 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 OF MICH. v. Insurance Comm'r, 270 N.W.2d 845, 403 Mich. 399, 1978 Mich. LEXIS 351 (Mich. 1978).

Opinions

Coleman, J.

Blue Cross and Blue Shield of Michigan (BCBSM) is seeking a declaratory judgment defining the nature and extent of the State Insurance Commissioner’s (Commissioner) regulatory powers over BCBSM as set forth by the Legislature in Public Acts 108 and 109 of 1939.1 No other relief has been requested.

After this case was briefed and argued, the Legislature’s Joint Administrative Rules Committee approved rules which affect the Commissioner’s powers.2 In addition, the new Public Health Code3 was enacted by the Legislature and, on July 25, 1978, signed by the Governor (some months after our opinion in this case initially was submitted). It contains, inter alia, extensive provisions regarding hospitals and health maintenance services effective on different future dates. We express no opinion as to the validity or meaning of these subsequent legislative actions. They are not before us.

[413]*413The circuit court upheld virtually all of the Commissioner’s claims of authority. We affirm in part and reverse in part. With respect to the issues presented, we hold:

1. The Commissioner’s continuing statutory authority over the rates charged to subscribers by BCBSM for hospital service coverage and the rates paid by BCBSM to hospitals for services rendered includes the power to disapprove a rate increase request to the extent that wasteful expenditures included in the rate base are found to be not "fair and reasonable”, but does not include the power to order BCBSM to implement specific cost containment programs. Management of BCBSM has been entrusted to its board of directors.

2. The Commissioner’s continuing statutory authority over BCBSM’s financial reserves does not include the power to disapprove directly or indirectly an increase in the rates of payment to physicians. The Commissioner’s only power with respect to reserves is to determine actuarially and require BCBSM to maintain reserves in an amount sufficient to assure the maturity of BCBSM’s contracts.

3. The Commissioner may consider the dollar amount budgeted for advertising in so far as it affects his statutory authority to approve subscriber rates for hospital services. He does not have the power to consider the content of BCBSM’s hospital service advertising.

4. The question of benefits was not raised by the parties and is not a matter in controversy. The circuit court was in error to have encompassed the matter in its opinion and we therefore hold that part of the judgment which concerns benefits to be void.

[414]*414I

The factual background of the case is pertinent only so far as it reveals the areas of disputed authority.

In 1975 BCBSM requested a subscriber fee rate increase of 33% totaling approximately 335 million dollars for the year. After the appointment of a master and extensive hearings, the Commissioner issued an order denying the rate increase. Accompanying that order was a voluminous opinion detailing the reasons why he was disapproving the increase. Important to the instant case are the portions of the opinion relating to overbedding, overutilization, physician screens (rates of payment to physicians)4 and advertising.

The Commissioner’s opinion addressed in detail the problem of overbedding and on the basis of several major studies (including one by the Department of Public Health) concluded that more than 23 million dollars of BCBSM’s requested rate increase would be paid to hospitals for the subsidization of excess beds. The opinion similarly addressed the problem of overutilization and concluded that an additional 23 million dollars of the requested rate increase would be spent on unnecessary health care. The opinion briefly discussed proposed increases in the physician screens and concluded that such increases were not justified. The opinion then examined the content of BCBSM’s advertising and concluded that nearly 700 thousand dollars of it was wasteful.

[415]*415Shortly after the Commissioner issued his opinion, BCBSM submitted a revised subscriber fee rate increase request that did not include the amounts determined by the Commissioner to be wasteful. The Commissioner approved this request in full. The amount of the increase was approximately 16%, totaling 163 million dollars for the year.

In June of 1975, BCBSM filed a complaint for declaratory judgment in circuit court challenging the nature and extent of the Commissioner’s regulatory power. The circuit court upheld the Commissioner’s authority with respect to virtually all of the actions he had taken during the 1975 rate review proceedings. The only area in which the court did not agree with the Commissioner concerned a contention that the Commissioner had the authority to require BCBSM to submit its proposed advertising in advance of publication to the Commissioner for approval. The court found no authority in the enabling legislation to support such a contention.

Subsequently, the petition for review of the rate increase originally filed by BCBSM in the circuit court was dismissed by stipulation of the parties. The only relief requested on appeal was by-pass to this Court and a review of the declaratory judgment defining the Commissioner’s powers. By-pass was granted. As a result, we are here engaged only in the task of determining whether the Commissioner had the authority to act, not whether he exercised authority reasonably during the 1975 rate review proceedings.

II

BCBSM is a unique creation. It is a non-profit, [416]*416tax-exempt "charitable and benevolent institution”,5 incorporated pursuant to special enabling legislation enacted by the Michigan Legislature in 1939,6 for the purpose of providing a mechanism for broad health care protection to the people of the State of Michigan.

BCBSM acts as an intermediary between its members, commonly known as the subscribers, and the hospitals and physicians who provide health care services, commonly known as the providers.

Most subscribers belong to groups such as labor unions, fraternal organizations, or governmental or professional associations. These groups independently determine what health care services they wish to secure for their members and then enter into individual contracts with BCBSM. Generally, the contracts provide that the subscribers will each pay a periodic subscription fee to BCBSM and BCBSM in return will arrange for the provision of the desired services. The subscribers pay the subscription fee regardless of whether they actually utilize the services. Thus, the cost of the services to any individual subscriber who does utilize them is shared by the entire group to which that subscriber belongs. In many cases, the subscription fee is paid by the subscriber’s employer. Often, such arrangements are the result of hard-fought collective bargaining agreements.

After the subscriber contracts have been negotiated, BCBSM enters into separate contracts with providers. The providers agree to furnish the desired services in return for a set fee to be paid by BCBSM. The providers who enter into such contracts are known as participating providers, while [417]*417those who do not are known as non-participating providers.

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Bluebook (online)
270 N.W.2d 845, 403 Mich. 399, 1978 Mich. LEXIS 351, Counsel Stack Legal Research, https://law.counselstack.com/opinion/blue-cross-blue-shield-of-mich-v-insurance-commr-mich-1978.