Blue Cross & Blue Shield of Tex., Inc. v. Commissioner

115 T.C. No. 12, 115 T.C. 148, 2000 U.S. Tax Ct. LEXIS 57
CourtUnited States Tax Court
DecidedAugust 18, 2000
DocketNo. 361-98
StatusPublished
Cited by2 cases

This text of 115 T.C. No. 12 (Blue Cross & Blue Shield of Tex., Inc. v. Commissioner) is published on Counsel Stack Legal Research, covering United States Tax 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 Tex., Inc. v. Commissioner, 115 T.C. No. 12, 115 T.C. 148, 2000 U.S. Tax Ct. LEXIS 57 (tax 2000).

Opinion

OPINION

Swift, Judge:

For 1992 and 1993, respectively, respondent determined deficiencies of $3,094,736 and $2,184,916 in petitioner’s Federal income taxes.

Unless otherwise indicated, all section references are to the Internal Revenue Code in effect for the years in issue, and all Rule references are to the Tax Court Rules of Practice and Procedure.

After settlement of some issues, the issue for decision is whether “savings” relating to “coordination of benefits” between petitioner and other health insurance companies qualify under the transition rule of the Omnibus Budget Reconciliation Act of 1990 (obra 1990), Pub. L. 101-508, section 11305(c)(3), 104 Stat. 1388-452. If not, we must decide whether the claimed “special” deductions relating thereto are allowable under the safe harbor rule of section 1.832-4(f)(2), Income Tax Regs.

We combine our findings of fact and opinion. Some of the facts have been stipulated and are so found.

During the years in issue, petitioner constituted an affiliated group of companies engaged in the business of providing medical health insurance to individuals and businesses. At the time the petition was filed, Blue Cross & Blue Shield of Texas, Inc., the common parent of petitioner’s affiliated group, maintained its principal place of business in Richardson, Texas. Hereinafter, petitioner will be referred to simply as Blue Cross.

Coordination of Benefits Provisions

Since the 1970’s, medical health insurance plans written by Blue Cross and by other health insurance companies typically contain nearly identical “coordination of benefits” (COB provisions) that are based on COB guidelines published by the National Association of Insurance Commissioners and that are required by most State insurance laws. The COB provisions establish payment responsibility, as between two or more health insurance companies, where insurance claims are filed that are covered by more than one health insurance company. The COB provisions are intended to prevent duplicate recovery on claims with respect to the same medical expenses.

COB provisions are applicable where medical expenses are incurred by individuals who are covered under two or more health insurance plans. A common COB situation arises in a family context where both parents are employed, with one parent covered by one group health plan and the other parent covered by another group health plan, with the spouse of each parent and each child also covered by both of the parents’ group health plans. In such a situation, each member of the family has duplicate and overlapping health insurance coverage — coverage under the father’s plan and coverage under the mother’s plan.

Under COB provisions, in such situations of duplicate and overlapping health insurance coverage, the various health insurance companies providing the overlapping insurance coverage are treated as either primarily or secondarily responsible for specific expenses and claims based on various and often arbitrary factors. For example, under COB provisions, medical expenses incurred by a husband would be treated as the primary responsibility of the medical insurance plan covering the husband directly as an employee. The insurance plan of the wife that covers the injured husband only as the spouse of the wife would be treated as secondarily responsible for the husband’s expenses.

As a further example, if the two health insurance plans of the parents cover medical expenses of an injured child only because the child is a dependent of the parents, under typical COB provisions, the plan that covers the parent who has the earlier birthday in the calendar year is treated as having primary responsibility for the child’s expenses.

Under COB provisions, health insurance companies that are treated as primarily responsible for medical expenses and claims (hereinafter referred to as primary insurers) are obligated to pay claims submitted to them as they would in the absence of any secondary responsibility by another insurance company.

Health insurance companies that are treated as secondarily responsible for medical expenses and claims (hereinafter referred to as secondary insurers) generally are obligated to pay only that portion of claims representing the difference between the amount the primary insurers pay and the total amount of the claims. For example, if a child is injured and claims are filed under health insurance plans maintained by both parents, the primary insurer (i.e., the insurer issuing the plan of the parent with the earlier birthday during the calendar year) would be responsible for the total portion of the claim covered under its plan (e.g., 80 percent of the amount of the claim), and the secondary insurer would be responsible for the remaining 20 percent of the claim.

COB Savings

Each year, the difference between what health insurance companies would pay if they were the primary insurer on all claims covered by their medical insurance plans and what they under COB provisions, as secondary insurers, actually pay on claims are referred to in the health insurance industry as COB “savings”. In the last illustration above, because the secondary insurer pays only 20 percent of the amount of the claim, 60 percent of the amount of the claim represents, to the secondary insurer, COB savings (i.e., the additional amount the secondary insurer would have had to pay if it had been primarily responsible for the claim). Under the COB provisions, secondary insurers, hypothetically “save” such amounts because they do not pay the additional portion of the claims that they would have paid if they had been the primary insurer.

Under COB provisions, once claims that have overlapping coverage have been filed and once primary and secondary responsibility as between two insurance companies for the claims has been identified, secondary insurers may wait for the primary insurers to calculate and to make their payments on pending claims before making the secondary payments (hereinafter referred to as the wait-and-pay approach). Alternatively, under COB provisions, secondary insurers may pay up front the full amount of the pending claims (up to the maximum coverage thereof) and then seek reimbursement from the primary insurers for amounts for which the primary insurers are responsible (hereinafter referred to as the pay- and-pursue approach).

Prior to and throughout the years in issue and unless paid in error, Blue Cross routinely used the wait-and-pay approach. Blue Cross only utilized the pay-and-pursue approach in the event a claimant did not disclose (or in the event Blue Cross’s COB investigation department did not identify) duplicate health insurance coverage that would trigger coordination of benefits.

Medicare-Related COB Savings

Another common situation that produces amounts included by insurance companies in COB savings involves retired employees and their spouses who are over 65 years of age and who are covered under insurance plans issued by health insurance companies and who also are covered under Medicare.

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Cite This Page — Counsel Stack

Bluebook (online)
115 T.C. No. 12, 115 T.C. 148, 2000 U.S. Tax Ct. LEXIS 57, Counsel Stack Legal Research, https://law.counselstack.com/opinion/blue-cross-blue-shield-of-tex-inc-v-commissioner-tax-2000.