Harvey v. CENTENE MANAGEMENT Co. Llc

357 F. Supp. 3d 1073
CourtDistrict Court, E.D. Washington
DecidedNovember 21, 2018
DocketNo. 2:18-CV-00012-SMJ
StatusPublished
Cited by6 cases

This text of 357 F. Supp. 3d 1073 (Harvey v. CENTENE MANAGEMENT Co. Llc) is published on Counsel Stack Legal Research, covering District Court, E.D. Washington primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Harvey v. CENTENE MANAGEMENT Co. Llc, 357 F. Supp. 3d 1073 (E.D. Wash. 2018).

Opinion

SALVADOR MENDOZA, JR., United States District Judge

Before the Court is Defendants Centene Management Company LLC and Coordinated *1077Care Corporation's Motion to Dismiss Second Amended Complaint, ECF No. 50. Defendants ask the Court to dismiss Plaintiff Cynthia Harvey's class action complaint alleging breach of contract and violation of the Consumer Protection Act ("CPA"), chapter 19.86 of the Revised Code of Washington ("RCW"). ECF No. 48. Harvey, a purchaser of Defendants' Ambetter health insurance policy, claims Defendants "misrepresented and made material omissions regarding the coverage actually provided by [their] Ambetter policy, which did not deliver the insurance services for which the [Washington State Office of the Insurance Commissioner] approved [the] filed rates." Id. at 7. Defendants argue Harvey fails to state a claim upon which relief can be granted. For the following reasons, the Court grants the motion in part and denies it in part.

BACKGROUND

On August 29, 2018, Harvey filed a Second Amended Complaint on behalf of herself and a putative class of Ambetter policyholders alleging Defendants breached their contracts and violated the CPA by misrepresenting and making material omissions regarding the coverage actually provided by their Ambetter policy, which did not deliver the insurance services for which the Insurance Commissioner approved the premiums. Id.

The complaint alleges Defendants "target low-income customers who qualify for substantial government subsidies while simultaneously providing coverage well below both what is required by law and what [they] represent[ ] to customers." Id. at 5. "[T]he provider network [Defendants] represented was available to Ambetter policyholders was in material measure, if not largely, fictitious. Members have difficulty finding - and in many cases cannot find - medical providers who will accept Ambetter insurance." Id. Defendants "misrepresent[ ] the number, location, and existence of purported providers by listing physicians, medical groups, and other providers - some of whom have specifically asked to be removed - as participants in their network and by listing nurses and other non-physicians as primary care providers."Id. "Defendants have even copied entire physician directories into their purported network lists for some areas, and have, in fact, listed medical students as part of their primary care provider network." Id. Defendants "listed those providers as being part of their network even though those providers were not actually part of the provider network for Ambetter." Id. at 19.

The complaint alleges "Defendants fail to disclose the true limitations of the coverage provided by its Ambetter policies." Id. at 6. "Defendants' sales materials omit the fact that [they] do[ ] not adequately monitor their network of providers. The Ambetter documentation also fails to disclose that [Defendants] do[ ] not consistently provide access to 'medically necessary care on a reasonable basis' without charging for out-of-network services." Id. Additionally, "Defendants routinely deny coverage for medical services, claiming that the provider did not show sufficient diagnostic evidence that the care was necessary." Id. at 20. "As a result of [Defendants] failing to pay providers for legitimate claims, a large number of medical providers reject Ambetter insurance, further reducing the provider network available to Ambetter's members." Id. at 6. "Defendants' provider network was and is so limited that holders of Ambetter policies would have to travel long distances to see a medical provider, if one legitimately within Defendants' network could be found at all." Id. at 19.

*1078Harvey purchased Defendants' Ambetter policy in December 2016. Id. at 21. In doing so, Harvey relied in part on Defendants' Ambetter plan brochure and plan summary. See id. at 21-22. These documents represent that the healthcare providers listed in Defendants' online directory are in network. Id. The documents "also purport to describe generally what services are covered and what are not, but are misleading by failing to indicate how few in-network providers would be available." Id. at 22. "For example, they indicate that emergency room services would be covered, although out-of-network charges might be incurred for out-of-network providers working in an otherwise covered emergency room. They fail to disclose, however, that in the Spokane area, during 2017, they had zero emergency room physicians who were in-network." Id. "Because Defendants failed to disclose that the limitations of the network coverage actually provided by the Ambetter policy fell far short of what they represented, Plaintiff ... was forced to incur a charge of $1,544 for treatment received from an emergency room doctor." Id.

Defendants also failed to cover individual elements of Harvey's healthcare visits because they were out of network. Id. "For example, Plaintiff ... received services from a covered doctor on March 17, 2017, but then received a bill from the lab used by that doctor. Similarly, Plaintiff ..., who has been identified as high risk for colorectal cancer, was advised by Coordinated Care to get a colonoscopy. Colonoscopies are within the preventive services required by the [Patient Protection and Affordable Care Act] to be included in coverage and are identified as covered in [Defendants'] Preventive Care brochure." Id. at 22. "When she got the colonoscopy from a covered doctor, however, her claims for two of the technicians involved in the procedure were denied." Id. at 22-23.

Harvey used Defendants' grievance and appeal process for each denial of coverage. Id. at 23. "In many cases, her appeal was ultimately successful, indicating that the initial denial of her claims was invalid. However, she was forced to complete the process of appeal, while providers were sending her bills and deeming her a credit risk." Id.

Putative class members "have had similar experiences, as admitted by Defendants in their May 17, 2018 letter to policyholders." Id. One putative class member "attempted to schedule an appointment with someone listed as a primary care physician on the provider network, only to find out that the person was a nurse practitioner" while "[a]nother person listed as a physician provider was a medical student." Id. at 23-24. Another putative class member "is a 60-year-old widow with medical issues" who "has consistently encountered difficulties with finding a medical provider willing to accept the Ambetter plan," which means "[s]he has to drive extraordinary distances to find a provider within Ambetter's network, an ordeal which can be insurmountable given her medical condition." Id. at 24.

The complaint alleges that, on December 12, 2017, the Insurance Commissioner ordered Coordinated Care to stop selling the 2018 Ambetter policy, finding "sufficient evidence to indicate that the Company failed to monitor its network of providers, failed to report its inadequate network to the Insurance Commissioner, and failed to file a timely alternative access delivery request to ensure that consumers receive access to healthcare providers." Id. at 7-8.

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Bluebook (online)
357 F. Supp. 3d 1073, Counsel Stack Legal Research, https://law.counselstack.com/opinion/harvey-v-centene-management-co-llc-waed-2018.