Fisher v. Health Insurance Plan

67 Misc. 2d 674, 324 N.Y.S.2d 732, 1971 N.Y. Misc. LEXIS 1309, 1972 Trade Cas. (CCH) 73,869
CourtNew York Supreme Court
DecidedSeptember 9, 1971
StatusPublished
Cited by9 cases

This text of 67 Misc. 2d 674 (Fisher v. Health Insurance Plan) is published on Counsel Stack Legal Research, covering New York Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Fisher v. Health Insurance Plan, 67 Misc. 2d 674, 324 N.Y.S.2d 732, 1971 N.Y. Misc. LEXIS 1309, 1972 Trade Cas. (CCH) 73,869 (N.Y. Super. Ct. 1971).

Opinion

J. Courtney McGroarty, J.

In this action brought by a group of policyholders and contract beneficiaries to enjoin Health Insurance Plan of Greater New York (hereinafter HIP) from changing its contract with them and others similarly situated, plaintiffs move for a temporary injunction. ■

HIP is a nonprofit membership corporation organized under article IX-C of the Insurance Law which offers some 755,000 [675]*675subscribers fully prepaid comprehensive medical care through medical groups. These medical groups, consisting of partnerships of physicians, render basic and specialized care in a group setting to subscribers under a medical group agreement with HIP, the most recent agreement having expired on July 31,1971. In effect, HIP operates a group practice plan which enables subscribers to prepay for comprehensive medical care.

To better serve, subscribers and to upgrade service, while enhancing incentives for participating physicans, HIP developed a new program proposal for 1971, forming the basis for negotiations for a new agreement with its medical groups. Twenty-six groups, represented by two organizations, continue to oppose HIP’s new program proposal and as of now have no agreement with HIP. To their credit these medical groups continue to serve HIP subscribers without contract while this dispute pends, receiving payment for their services on a capitation basis as provided by the expired contract. Five other medical groups, however, serving about 185,000 subscribers, have agreed to a new contract, embodying HIP’s new 1971 program proposal.

Recognizing the strong resistance to its program proposal by the 26 medical groups, and the possibility that it might not be able to negotiate a satisfactory agreement wtih them, HIP prepared to deal with the problem by making appropriate preparations to protect subscribers. HIP decided that it would serve the best interests of subscribers to give them an opportunity to transfer to other medical groups in their area if the medical groups to which they belonged refused to serve them, or, if there were no such other groups available, to place them on an indemnity coverage plan until such time as HIP could obtain coverage for them through a selected medical group or an alternate medical group, such change to be effected by a proposed rider to their HIP policy. On July 1 direct policyholders and contractor groups were so notified by letter, but before HIP could also notify all individual subscribers it was stayed from proceeding further by the restraining order herein.

Under the proposed rider a subscriber unable to obtain services from his medical group by reason of termination of the medical agreement who is unable or unwilling to transfer to another medical group under contract with HIP may select the same or any other medical group or physician on an individual basis and will be indemnified according to a fee schedule. HIP proposes to set the fee schedule at the actuarial equivalent of present capitation payments to its medical gToups and at the indemnity schedules it now pays for medical services to some 5,000 sub[676]*676scribers in areas without medical groups under contract with HIP.

Plaintiffs object to the proposed rider, claiming that it substitutes indemnification payments on a fee schedule basis for each item of medical care for fully prepaid comprehensive medical care HIP is obligated to furnish. Plaintiffs argue that subscribers rely upon HIP for fully paid comprehensive medical care without further cost to them. If the proposed rider is implemented, doctors’ regular fees would be charged and the difference between fees charged and HIP’s fee schedule allowances would have to be paid by subscribers, thereby violating HIP’s policy agreement by substituting indemnification payments for prepaid comprehensive medical coverage. Plaintiffs say that, considering the accumulated burden of comprehensive damage that could result by reason of such contract breach, HIP might face insolvency.

Plaintiffs also urge that HIP’s insistence that contracting medical groups may not similarly contract with other carriers is illegal and violates section 340 of the General Business Law prohibiting restraint of trade and therefore jeopardizes continuation of medical care under such illegal contract. In view of the irreparable damages that plaintiffs claim may result, they ask for a temporary injunction restraining HIP until trial from implementing the proposed rider or in any other way changing present practice and procedures which have been followed for many years and which rights are guaranteed to them by their policies and contracts with HIP.

Plaintiffs bring this action on behalf of themselves and as a, representative class action on behalf of all other policyholders and contract beneficiaries similarly situated.

CPLR 1005 (subd. [a]) authorizes one or more persons to sue for the benefit of all “ Where the question is one of a common or general interest of many persons ’ ’. The action must involve an interest common to all members. In this case, some 185,000 policyholders and contract beneficiaries served by 5 medical groups that have contracted with HIP, have no interest in common with plaintiffs or others in enjoining implementation of the proposed rider, as they are not affected by it. In addition, many subscribers might well disagree with the action taken by these plaintiffs, perhaps preferring to have the benefit of the proposed rider to fall back on if their medical groups should be unable or unwilling to serve them. Not all subscribers are injured by the proposed rider— only those who may be in need of medical care during their policy term and are unable to obtain it on a fully prepaid basis. Each such wronged subscriber may deter[677]*677mine for .himself what remedy to seek. Separate wrongs to separate persons, though committed by' similar means and pursuant to a single plan, do not alone create a common or general interest in those wronged (Society Milion Athena v. National Bank, of Greece, 281 N. Y. 282; Brenner v. Title Guar. & Trust Co., 276 N. Y. 230). Class actions may not be maintained when the asserted wrongs are individual to the different persons and each aggrieved person may determine for himself the remedy he will seek and may be subject to a defense not' available to the others (Gaynor v. Rockefeller, 15 N Y 2d 120). These plaintiffs have no interest in any cause of action or recovery by others and it may well be that the remedy desired by other policyholders or beneficiaries differs from that sought here, i.e., to enjoin HIP from changing its contract regardless of whether it is able to continue to furnish fully paid comprehensive medical care through medical groups. This action deprives the other policyholders and beneficiaries of their choice of remedies (Onofrio v. Playboy Club of New York, 15 N Y 2d 740). The class action is improperly brought; it cannot stand.

Having determined that no class action lies, the question remains whether these plaintiffs may individually maintain this action for a permanent injunction. Viewing the-matter in that light, the question presented is whether these plaintiffs may, if HIP is unable to conclude a satisfactory agreement with the 26 medical groups and is therefore unable to fulfill its policy obligations, enjoin HIP from implementing an alternate plan. It is not certain that these plaintiffs may need medical care during their present policy terms or that HIP may be unable to provide fully prepaid medical care if the need arises.

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Bluebook (online)
67 Misc. 2d 674, 324 N.Y.S.2d 732, 1971 N.Y. Misc. LEXIS 1309, 1972 Trade Cas. (CCH) 73,869, Counsel Stack Legal Research, https://law.counselstack.com/opinion/fisher-v-health-insurance-plan-nysupct-1971.