Care Choices HMO v. Engstrom

Court of Appeals for the Sixth Circuit·Decided May 30, 2003·No. 01-2717·Published

Opinion

5(&200(1'(' )25 )8//7(;7 38%/,&$7,21 3XUVXDQW WR 6L[WK &LUFXLW 5XOH   &DUH&KRLFHV+02 1RV (/(&7521,& &,7$7,21  )(' $SS 3 WK &LU Y(QJVWURP )LOH 1DPH DS

7KDGGHXV(0RUJDQ)5$6(575(%,/&2&.'$9,6 81,7('67$7(6&28572)$33($/6 '81/$3 /DQVLQJ 0LFKLJDQ IRU $SSHOODQW  &KDUOHV *RWWOLHE*277/,(% *25(1%LQJKDP)DUPV0LFKLJDQ )257+(6,;7+&,5&8,7 IRU$SSHOOHH BBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBB 23,1,21 &$5( &+2,&(6 +02 ; BBBBBBBBBBBBBBBBB 3ODLQWLII$SSHOODQW   .(11('<&LUFXLWsXGJH &URVV$SSHOOHH  1RV  , Y !  2YHUWKHODVWWZRGHFDGHV&RQJUHVVKDVVWUXJJOHGWRUHGXFH  WKHFRVWRIWKH0HGLFDUHSURJUDP2QHHIIRUWLQWKLVVWUXJJOH (/,=$%(7+ (1*67520  LV  86& † PP ZKLFK SHUPLWV WKH &HQWHU IRU 'HIHQGDQW$SSHOOHH  0HGLFDUHDQG0HGLFDLG6HUYLFHV m&06l WKHDGPLQLVWUDWRU &URVV$SSHOODQW  RI 0HGLFDUH WR FRQWUDFW ZLWK SULYDWH KHDOWK PDLQWHQDQFH  RUJDQL]DWLRQV m+02Vl WRSURYLGHUHSODFHPHQWFRYHUDJHIRU 1 0HGLFDUHHOLJLEOHLQGLYLGXDOV $SSHDOIURPWKH8QLWHG6WDWHV'LVWULFW&RXUW IRUWKH(DVWHUQ'LVWULFWRI0LFKLJDQDW'HWURLW 3ODLQWLII&DUH&KRLFHV+02LVOLFHQVHGE\&06WRSURYLGH 1Rn9LFWRULD$5REHUWV'LVWULFWsXGJH UHSODFHPHQW 0HGLFDUH FRYHUDJH  'HIHQGDQW (OL]DEHWK (QJVWURP LV D 0HGLFDUHHOLJLEOH LQVXUHG FRYHUHG E\ &DUH $UJXHG0D\ &KRLFHV +02  ,Q  (QJVWURP VOLSSHG DQG IHOO LQ D VXSHUPDUNHWVXVWDLQLQJVHULRXVLQMXULHV&DUH&KRLFHV+02 'HFLGHGDQG)LOHG0D\ SDLG  LQ KHDOWK FDUH H[SHQVHV UHVXOWLQJ IURP (QJVWURPjV LQMXULHV (QJVWURP EURXJKW D SHUVRQDO LQMXU\ %HIRUH.(11('<6,/(5DQG*,/0$1&LUFXLW ODZVXLW DJDLQVW WKH VXSHUPDUNHW ZKLFK VKH VHWWOHG IRU sXGJHV   7KDW VHWWOHPHQW DZDUG ZDV SDLG E\ WKH VXSHUPDUNHWjVWKLUGSDUW\OLDELOLW\LQVXUHU BBBBBBBBBBBBBBBBB 2Q0D\&DUH&KRLFHV+02ILOHGVXLWLQIHGHUDO &2816(/ GLVWULFW FRXUW VHHNLQJ D GHFODUDWLRQ WKDW LW ZDV HQWLWOHG WR UHFRXSWKHPHGLFDOH[SHQVHVLWKDGSDLGRXWRIWKHVHWWOHPHQW $5*8('*UDKDP.&UDEWUHH)5$6(575(%,/&2&. '$9,6  '81/$3 /DQVLQJ 0LFKLJDQ IRU $SSHOODQW &KDUOHV*RWWOLHE*277/,(% *25(1%LQJKDP)DUPV  &06 ZDV SUHYLRXVO\ NQRZQ E\ WKH WLWOH +HDOWK &DUH )LQDQFLQJ 0LFKLJDQIRU$SSHOOHH21%5,()*UDKDP.&UDEWUHH $GPLQLVWUDWLRQ m+&)$l 

 1RV &DUH&KRLFHV+02   &DUH&KRLFHV+02 1RV Y(QJVWURP Y(QJVWURP

PRQH\&DUH&KRLFHV+02DUJXHVWKDWLWKDVDSULYDWHULJKW ,, RIDFWLRQXQGHU86&†PP H  ZKLFKSURYLGHV WKDW 0HGLFDUHVXEVWLWXWH +02V DUH SHUPLWWHG WR VHHN :HUHYLHZWKHGLVWULFWFRXUWjVGHFLVLRQUHJDUGLQJVXEMHFW UHLPEXUVHPHQW ZKHQ DQ LQVXUHG UHFHLYHV EHQHILWV IURP PDWWHUMXULVGLFWLRQGHQRYR$PHULFDQ)HGjQRI6WDWH&RXQW\ DQRWKHU VRXUFH RI LQVXUDQFH  7KH VWDWXWH LV VLOHQW DV WR DQ DQG0XQ(PSOR\HHV/RFDOY3ULYDWH,QGXV&RXQFLORI +02jVUHPHGLHVIRUREWDLQLQJUHLPEXUVHPHQW 7UXPEXOO&RXQW\)G WK&LU  7KH GLVWULFW FRXUW JUDQWHG (QJVWURPjV PRWLRQ WR GLVPLVV 7KHVWDWXWHDWLVVXHLQWKLVFDVH86&†PP H   EDVHGRQODFNRIVXEMHFWPDWWHUMXULVGLFWLRQ&DUH&KRLFHV SURYLGHVWKDW +02Y(QJVWURP)6XSSG ('0LFK  :H DUH DVNHG LQ WKLV FDVH WR GHFLGH ZKHWKHU  86& 1RWZLWKVWDQGLQJDQ\RWKHUSURYLVLRQRIODZWKHHOLJLEOH †PP H  FRQWDLQVDQLPSOLHGSULYDWHULJKWRIDFWLRQLQ RUJDQL]DWLRQPD\ LQWKHFDVHRIWKHSURYLVLRQRIVHUYLFHV IHGHUDOFRXUWIRU0HGLFDUHVXEVWLWXWH+02V:HKROGWKDW WRDPHPEHUHQUROOHGXQGHUWKLVVHFWLRQIRUDQLOOQHVVRU LWGRHVQRWDQGDIILUPWKHGLVWULFWFRXUWjVGHFLVLRQ LQMXU\IRUZKLFKWKHPHPEHULVHQWLWOHGWREHQHILWVXQGHU D ZRUNPDQjV FRPSHQVDWLRQ ODZ RU SODQ RI WKH 8QLWHG 6WDWHV RU D 6WDWH XQGHU DQ DXWRPRELOH RU OLDELOLW\ LQVXUDQFHSROLF\RUSODQLQFOXGLQJDVHOILQVXUHGSODQRU XQGHU QRIDXOW LQVXUDQFH  FKDUJH RU DXWKRUL]H WKH  &DUH &KRLFHV DOVR SXUVXHG D FRQWUDFWXDO ULJKW WR UHLPEXUVHPHQW LQ SURYLGHURIVXFKVHUYLFHVWRFKDUJHLQDFFRUGDQFHZLWK VWDWH FRXUW 7KH 6XPPDU\ 3ODQ 'HVFULSWLRQ FRQWDLQHG LQ (QJVWURPjV WKHFKDUJHVDOORZHGXQGHUVXFKODZRUSROLF\o SROLF\ SURYLGHV WKDW mLI \RX >WKH LQVXUHG@ FROOHFW PRQH\ IURP D WKLUG SDUW\ EHFDXVH RI DQ DLOPHQW LQMXU\ RU GLVHDVH WKH PRQH\ PXVW EH DSSOLHG WR $ WKHLQVXUDQFHFDUULHUHPSOR\HURURWKHUHQWLW\ZKLFK \RXU &DUH &KRLFHV 6HQLRU KHDOWKFDUH H[SHQVHV ,W GRHVQjW PDWWHU LI WKH XQGHUVXFKODZSODQRUSROLF\LVWRSD\IRUWKHSURYLVLRQ PRQH\ UHVXOWV IURP D OHJDO DFWLRQ RU VHWWOHPHQWl 2Q sDQXDU\   &DUH &KRLFHV +02 ILOHG D 1RWLFH RI &RQWUDFWXDO /LHQ LQ 0LFKLJDQ VWDWH RIVXFKVHUYLFHVRU FRXUW VHHNLQJ UHLPEXUVHPHQW RXW RI WKH VHWWOHPHQW DZDUG IRU WKH H[SHQVHV LW SDLG DV D UHVXOW RI (QJVWURPjV LQMXULHV 2Q $SULO   (QJVWURP % VXFKPHPEHUWRWKHH[WHQWWKDWWKHPHPEHUKDVEHHQ ILOHG D PRWLRQ WR YRLG RU GLVFKDUJH WKH OLHQ FODLP 2Q 0D\   WKH SDLGXQGHUVXFKODZSODQRUSROLF\IRUVXFKVHUYLFHV VWDWH FRXUW JUDQWHG WKDW PRWLRQ FRQFOXGLQJ WKDW  (QJVWURP RZHG QR PRQH\ WR &DUH &KRLFHV +02 DQG  &DUH &KRLFHV +02 LV QRW HQWLWOHG $EVHQW DQ H[SUHVV SULYDWH ULJKW RI DFWLRQ IHGHUDO FRXUWV WR D OLHQ DJDLQVW (QJVWURPjV UHFRYHU\ IURP WKH VXSHUPDUNHW %HFDXVH WKH PD\LQFHUWDLQFLUFXPVWDQFHVILQGDQLPSOLHGULJKWRIDFWLRQ H[LVWHQFH RI VXEMHFW PDWWHU MXULVGLFWLRQ LQ IHGHUDO FRXUW WXUQV RQ WKH TXHVWLRQ RI ZKHWKHU &DUH &KRLFHV KDV D YDOLG FODLP XQGHU  86& ,Q&RUWY$VK86  WKH6XSUHPH&RXUW †  ZH QHHG QRW UHDFK DQ\ RI WKH LVVXHV SHUWDLQLQJ WR LWV DVVHUWHG RXWOLQHG IRXU IDFWRUV WR FRQVLGHU ZKHQ GHWHUPLQLQJ WKH FRQWUDFW FODLP H[LVWHQFHRIDQLPSOLHGVWDWXWRU\FDXVHRIDFWLRQ  )LUVWLVWKHSODLQWLIIRQHRIWKHFODVVIRUZKRVHHVSHFLDO &DUH &KRLFHV DOVR DVVHUWV WKDW  &)5 †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† PP H  LWVHOI 7KLUGLVLWFRQVLVWHQWZLWKWKHXQGHUO\LQJSXUSRVHVRIWKH 1RV &DUH&KRLFHV+02   &DUH&KRLFHV+02 1RV Y(QJVWURP Y(QJVWURP

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

Care Choices HMO v. Engstrom, (6th Cir. 2003).

Care Choices HMO v. Engstrom (Care Choices HMO v. Engstrom) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.