CSAHA/UHHS-Canton, Inc. v. Aultman Health Found.

2012 Ohio 897
CourtOhio Court of Appeals
DecidedMarch 5, 2012
Docket2010CA00303
StatusPublished
Cited by8 cases

This text of 2012 Ohio 897 (CSAHA/UHHS-Canton, Inc. v. Aultman Health Found.) is published on Counsel Stack Legal Research, covering Ohio Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
CSAHA/UHHS-Canton, Inc. v. Aultman Health Found., 2012 Ohio 897 (Ohio Ct. App. 2012).

Opinion

[Cite as CSAHA/UHHS-Canton, Inc. v. Aultman Health Found., 2012-Ohio-897.]

COURT OF APPEALS STARK COUNTY, OHIO FIFTH APPELLATE DISTRICT

CSAHA/UHHS-CANTON, INC. JUDGES: DBA MERCY MEDICAL CENTER Hon. William B. Hoffman, P.J. Hon. Patricia A. Delaney, J. Plaintiff-Appellee Hon. Donna J. Carr, J. (sitting by Assignment by the Ohio Supreme -vs- Court)

AULTMAN HEALTH FOUNDATION Case No. 2010CA00303 AULTMAN CORPORATION AULTMAN HOSPITAL, AND MCKINLEY LIFE INSURANCE OPINION COMPANY

Defendants-Appellants

CHARACTER OF PROCEEDING: Appeal from the Stark County Court of Common Pleas, Case No. 2007CV05277

JUDGMENT: AFFIRMED, IN PART; AND REVERSED, IN PART

DATE OF JUDGMENT ENTRY: March 5, 2012

APPEARANCES:

For Plaintiff-Appellee For Defendants-Appellants

LEE E. PLAKAS ALLEN SCHULMAN, JR. CHRISTOPHER M. HURYN BRIAN L. ZIMMERMAN EDMOND J. MACK Schulman & Zimmerman Tzangas, Plakas, Mannos & Raies, LTD. 236 Third St. S.W. 220 Market Avenue South, 8th Floor Canton, Ohio 44702 Canton, Ohio 44702

DANIEL R. WARREN JOHN R. GALL SCOTT C. HOLBROOK KEITH SHUMATE KAREN E. SWANSON HAAN PHILOMENA M. DANE Baker & Hostetler, LLP HEATHER L. STUTZ 3200 National City Center CHRISTOPHER F. HAAS 1900 East Ninth Street Squire, Sanders & Dempsey, LLP. Cleveland, Ohio 44114 41 South High Street 2000 Huntington Center Columbus, Ohio 43215-6197 Stark County, Case No. 2010CA00303 2

Per Curiam

{¶1} Defendants-Appellants, Aultman Health Foundation, AultCare Corporation,

Aultman Hospital, and McKinley Life Insurance Company appeal the October 19, 2010

judgment entries entered by the Stark County Court of Common Pleas. Plaintiff-

Appellee is CSAHA/UHHS-Canton, Inc. dba Mercy Medical Center.

STATEMENT OF THE FACTS AND THE CASE

{¶2} The citizens of Stark County and surrounding area are served by two full-

service hospitals located in Canton, Ohio -- Mercy Medical Center and Aultman

Hospital. The local population is fortunate to be able to choose between these two

distinguished hospitals for their health care needs. However, not as well known to the

local population is the competition between Mercy Medical Center and Aultman Hospital

to serve the community’s health care needs. A competitive business atmosphere drives

health care choice. An individual patient’s health choice is often dictated by his or her

employer, who provides health insurance to its employees. The employer chooses the

health insurance provider. The choice of health insurance provider is typically made

upon the advice of an insurance broker. What follows is a narrative of the interplay of

insurance company, insurance broker, and customer and the competitive business of

health care services between Mercy Medical Center and Aultman Hospital.

{¶3} Aultman Health Foundation (“AHF”) is a non-profit corporation and parent

company of Aultman Hospital, AultCare Corporation, and McKinley Life Insurance

Company. Aultman Hospital is a non-profit hospital. AultCare Corporation (“AultCare”)

is a joint venture between AHF and a local group of physicians, whom have no

monetary ownership in AultCare, but serve in the governance of AultCare. AultCare is a Stark County, Case No. 2010CA00303 3

non-profit, third-party administrator (“TPA”) licensed with the Ohio Department of

Insurance. As a TPA, AultCare does not provide insurance but rather provides

administrative services, such as reviewing and paying claims. AultCare enters into

contracts with hospitals and physicians to create a “network” through which AultCare’s

customers receive medical services at contracted prices. McKinley Life Insurance

Company (“McKinley”) is an insurance company licensed through the Ohio Department

of Insurance. McKinley provides various insurance products to employer groups and

individuals. While AultCare and McKinley are separate companies, the name

“AultCare” is used to refer to both entities. A customer with AultCare receives health

care from providers within the AultCare network and Aultman Hospital is the only “in

network” hospital.

{¶4} Mercy Medical Center (“Mercy”) is also a non-profit hospital. Mercy does

not own an insurance company; however, it does own a 20% interest in Ohio Health

Choice (“OHC”). OHC sells access to a network of hospitals and physicians, including

Mercy. Mercy also obtains patients through managed care contracts it has entered into

with almost 40 insurance companies such as Medical Mutual, Anthem, Aetna, and

United Healthcare. Mercy does not accept health insurance coverage by AultCare.

{¶5} Insurance companies and TPAs market and sell their products through

independent insurance brokers. Independent brokers are licensed by insurance

companies to sell that company’s products, often among others. The brokers act as

intermediaries between the insurance companies and businesses. Insurance contracts

typically last for one year. At that time, the employers will decide whether to renew their

insurance coverage or obtain new coverage. Brokers will contact insurers on the Stark County, Case No. 2010CA00303 4

employer’s behalf, obtain quotes for coverage, present coverage alternatives to the

employer, and advise the employer on the various options.

{¶6} Brokers generally receive compensation through the insurance companies

for the sale of their products. All insurers pay a base commission to their broker, which

is generally calculated as a percentage of the insurance premium paid by the client.

There are other forms of compensation, such as bonuses for new business placed with

the insurer or retention bonuses for clients who renew their coverage. Brokers are not

required to disclose the compensation received from insurance companies unless the

client requests that information. Confidentiality agreements between brokers and

insurance companies are common within the industry.

{¶7} Aultman originally marketed its managed care plans through its own in-

house sales force. In 1997, Aultman changed its methods to increase its sales from

independent brokers and created the Conversion Support Program (“CSP”) to increase

AultCare membership. The CSP was a bonus program established by Aultman for a

select group of brokers. The amount of the bonus was dependent on the number of

“lives” converted to the AultCare insurance program. A broker could be paid up to $200

for every “life” the broker converted to AultCare. Aultman paid the brokers 60% of the

bonus in the first year if the broker’s client selected AultCare as their health insurance

provider and the broker would receive the remaining 40% bonus if the client renewed

with AultCare for two additional years. The brokers were required to sell a minimum

amount of business to qualify for the bonus, and had to maintain a specified retention

rate. The broker was penalized with fines of $40 per “life” if the broker failed to retain up Stark County, Case No. 2010CA00303 5

to 97% of their AultCare lives per year. If the client did not renew with AultCare, the

broker would not receive the remaining 40% bonus.

{¶8} The brokers who participated in the CSP were required to enter into

confidentiality agreements where the broker could not inform their clients they were

receiving compensation from Aultman if the client chose AultCare as their insurance

provider. In 2004, Aultman waived the confidentiality provision.

{¶9} The launch of the CSP caused AultCare to become the major health

insurance provider in the area.

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