Estate of Kwan Rim v. Wellmark, Inc. d/b/a Wellmark BlueCross and BlueShield of Iowa and Wellmark Health Plan of Iowa, Inc.

• Court: Court of Appeals of Iowa
• Decided: June 19, 2019
• Docket: 18-0922
• Status: Published

Opinion

IN THE COURT OF APPEALS OF IOWA

No. 18-0922 Filed June 19, 2019

ESTATE OF KWAN RIM, Plaintiff-Appellant,

vs.

WELLMARK, INC. d/b/a WELLMARK BLUE CROSS AND BLUE SHIELD OF IOWA and WELLMARK HEALTH PLAN OF IOWA, INC., Defendants-Appellees. ________________________________________________________________

Appeal from the Iowa District Court for Polk County, Douglas F. Staskal,

Judge.

A decedent’s estate appeals from a district court review affirming the denial

of health insurance coverage for a vast majority of an extended hospital stay.

AFFIRMED.

Rebecca A. Brommel of Brown, Winick, Graves, Gross, Baskerville and

Schoenebaum, P.L.C., Des Moines, for appellant.

Mitchell R. Kunert of Nyemaster Goode, P.C., Des Moines, for appellees.

Heard by Vaitheswaran, P.J., and Potterfield and Tabor, JJ. 2

VAITHESWARAN, Presiding Judge.

A retired University of Iowa employee sought coverage from his health

insurance plan for an extended hospital stay in South Korea. This appeal flows

from the denial of coverage for the vast majority of his hospitalization.

I. Background Facts and Proceedings

Kwan Rim was enrolled in the UIChoice Retiree group health plan,

sponsored and funded by the University of Iowa and administered by Wellmark

Blue Cross and Blue Shield of Iowa (Wellmark). He fell in his South Korean

apartment and was hospitalized for more than a year.

Rim filed a claim with Wellmark for hospital services provided between

October 8, 2014, and December 4, 2015. Wellmark concluded the services

received from January 1, 2015, through December 4, 2015, were “considered long

term care and custodial care,” which were “not covered” by his plan.

Rim sought external review. See Iowa Code ch. 514J (2016) (governing

“External Review of Health Care Coverage Decisions”); see also id. § 514J.105

(“A covered person or the covered person’s authorized representative may make

a request for an external review of a final adverse determination.”). An

independent review organization (IRO)1 approved by the Iowa Insurance

Commissioner2 evaluated the medical records from the South Korean hospital and

found certain “clinical records” were “largely illegible as they [were] written in

1 An “independent review organization” is defined as “an entity that conducts independent external reviews of adverse determinations and final adverse determinations.” Iowa Code § 515J.102(26). 2 With one exception, “all requests for external review shall be made in writing to the commissioner.” Iowa Code § 514J.105. 3

Korean font” and “[t]he format of the records [was] difficult to determine, and the

headings of the sections of the documentation were not translated.” The IRO

overturned Wellmark’s denial of coverage from January 1, 2015, through

January 31, 2015, but affirmed the denial of coverage for the balance of Rim’s

hospitalization, reasoning the stay was medically unnecessary.

Rim filed a petition for judicial review. See id. § 514J.110(2)(a) (authorizing

petitions for judicial review of external review decisions). Rim cited the judicial

review standards of Iowa Code chapter 17A, governing review of agency action.

Wellmark answered and denied “the alleged applicability of Iowa Code Chapter

17A.” Meanwhile, Rim passed away, and his estate was substituted as a party.3

The district court declined to apply the judicial review standards of chapter

17A. The court next addressed Rim’s concern with the IRO’s inability to decipher

certain records and concluded there was “nothing in the law that required Wellmark

to have Rim’s medical records translated into English.” Finally, the court affirmed

the IRO’s determination that the bulk of the hospital stay was medically

unnecessary. Rim appealed.

II. Applicability of Iowa Code Chapter 17A

Rim insists the judicial review provisions of Iowa Code chapter 17A govern

review of the IRO’s decision. We are unpersuaded.

Chapter 17A governs review of agency action. See id. § 17A.1(2). An

agency is defined as a “board, commission, department, officer or other

3 We will refer to the estate as Rim. 4

administrative unit of the state.” Id. § 17A.2(1). The IRO is not a unit of the state.

It is a limited liability corporation based in Utah.

Rim responds that the Iowa Insurance Division’s involvement triggered the

judicial review standards of chapter 17A. But Rim does not challenge the

commissioner’s conduct; he exclusively challenges the IRO’s decision. See id.

§ 514J.110(2)(b) (stating the Iowa insurance commissioner “shall not be named as

a respondent unless the petitioner alleges action or inaction by the commissioner

under the standards articulated in section 17A.19, subsection 10”). The

commissioner’s approval of the IRO and oversight of the external review process

cannot transform the decision into “agency action,” as Rim contends, because the

definition of “agency action” necessarily harkens back to the definition of agency.

As the IRO is not an agency and Rim does not contest any action of the Insurance

Division, which is an agency, the standards governing review of agency action are

inapplicable.

III. Obligation to Translate Records

Rim next contends the district court erred in determining Wellmark had no

duty to provide the IRO with translated medical records. We need not decide

whether Wellmark has a general duty to translate medical records from other

languages to English because, in this case, the South Korean medical records

contained enough English on which to ground the coverage decision. As the

district court stated, “it is very clear that the [IRO] reviewer had no trouble

determining from the records the exact injuries that Rim suffered when he fell as

well as the exact nature of the medical care and procedures he underwent at [the

South Korean hospital] as a result.” The court also noted that “the reviewer did not 5

rely solely on the medical records in conducting the review. He also relied on

billing statements and on standard medical texts and references regarding the

usual nature, including length of hospital stay, of treatment for injuries of the type

Rim suffered.”

Because the medical records were sufficiently intelligible to render a

coverage decision by an English reader, we also need not determine who should

bear the costs of translation, if translation were required.

IV. Decision of the Independent Review Organization

Finally, Rim contends the district court erred in affirming the IRO’s decision.

He bases his contention on the insufficiency of the records. As discussed, we

discern no error in the district court’s conclusion that the records were sufficient.

We turn to the IRO’s fact findings. Per statute, “[t]he findings of fact by the

independent review organization conducting the external review are conclusive

and binding on appeal.” Id. § 514J.110(2)(b); see also Gjerde v. United

HealthCare Plan of the River Valley, Inc., No. 13-1624, 2014 WL 5862034, at *6

(Iowa Ct. App. Nov. 13, 2014). The IRO found “[t]he patient did not require an

inpatient hospitalization level of care for the entirety of 2015. The records do not

support the patient’s rehabilitation provided at a level that was appropriate for an

inpatient level of care, and could have been completed at a lower level of care.”

This finding is binding on appeal. Because it is undisputed that Rim’s policy

disallowed coverage for a lower level of care, it follows that the IRO did not err in

denying coverage for the bulk of Rim’s hospital stay.

We affirm the district court ruling on judicial review of the IRO’s decision.