Hospital Service Corp. of Rhode Island v. West

308 A.2d 489, 112 R.I. 164, 1973 R.I. LEXIS 968
CourtSupreme Court of Rhode Island
DecidedAugust 10, 1973
Docket1901-M.P
StatusPublished
Cited by10 cases

This text of 308 A.2d 489 (Hospital Service Corp. of Rhode Island v. West) is published on Counsel Stack Legal Research, covering Supreme Court of Rhode Island primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Hospital Service Corp. of Rhode Island v. West, 308 A.2d 489, 112 R.I. 164, 1973 R.I. LEXIS 968 (R.I. 1973).

Opinion

*165 Paolino, J.

The petitioners, Hospital Service Corporation of Rhode Island, hereinafter referred to as Blue Cross, and Rhode Island Medical Society Physicians Service, hereinafter referred to as Blue Shield, are nonprofit service corporations engaged in providing health care insurance to their subscribers. They brought this petition for certiorari under G. L. 1956 (1969 Reenactment) §42-35-16, as amended hy P. L. 1972, ch. 169, sec. 30. 1 The petitioners, claiming that they are aggrieved by a final judgment of the Superior Court involving an appeal from a decision of the respondent, Albert B. West, Director of the Department of Business .Regulation, filed this petition to review the action of that court. 2 We issued the writ, and pursuant thereto the pertinent records have been certified to this court.

Among the types of coverage provided by petitioners is the jointly underwritten Plan 65 which is designed to supplement the benefits afforded by the Federal Medicare program to those who are 65 years of age or older. On March *166 28, 1972, petitioners, pursuant to the provisions of G. L. 1956 (1968 Reenactment) §27-19-6 3 and §27-20-6 4 as amended by P. L. 1970, ch. 53, sec. 1, applied to respondent for an increase of $1.13 per month in Plan 65 membership rates for the rate year July 1, 1972 through June 30, 1973, a percentage increase of 15.75. The petitioners said in their application that such an increase was necessitated by increases in costs mandated by the Medicare program, over which costs petitioners had no control, and to provide a month's reserve.

Seymour A. Fenichel, a qualified actuarial expert in the field of health insurance, and Frank R. Adae, an executive vice president of Blue Cross, testified for petitioners at the *167 hearing before respondent. Mr. Fenichel explained that Part A of Plan 65 protects its members from hospitalization costs to which they are exposed by the Federal Medicare program, while Part B serves the same function for physicians’ fees. In supplementing Medicare payments during the 1971 calendar year, petitioners were obliged to pay the first $60 of a member’s hospital bill and $15 daily for such confinement from the 61st day to the 90th day thereof. The self-executing provisions of the Medicare law increased the initial deductible to $68 with a consequent increase to $17 per day for the calendar year 1972. It was assumed that the minimal increase for 1973 would be $72, although other Blue Cross plans were estimating an increase to $76.

Under Part B petitioners must pay the first $50 of the subscriber’s physicians’ fees and 20 per cent of the balance. As charges and prices have risen in our economy the amount of dollars payable by petitioners has risen proportionately. Mr. Fenichel testified about the anticipated increase in physicians’ fees and in the use of doctors and hospitals by the members. With regard to such fees and the additional costs expected in the handling of claims, the projected increase was limited by him strictly in accordance with federal regulatory provisions.

Mr. Fenichel pointed out that $6,281,422 was required just to meet claims and expenses. He then spoke about the reserves. As of July 1, 1972, he forecast a deficit balance in reserves of $56,868 making it necessary to add this amount to required income in order to bring the deficit balance to a zero position. In addition, to the extent that management wants to have prudent assurance against insolvency by virtue of experience, some degree of margin not in excess of projections is needed. On December 31, 1971, the total reserve position for Blue Cross alone was $4,979,000. He testified that reserves are only a matter of judgment and, having seen the practice of other Blue Cross *168 plans and being aware of the thinking of those concerned with the problem, it was his judgment that one month in reserve for Plan 65 was minimal. This amount of reserve was determined by the boards of directors of petitioners as necessary and reasonable. As a consequence, the sum of $523,452 (l/12th of total projected expenses) was included as needed income. To the resultant sum was added $27,323, the factor for direct pay-cycle loss — this resulted from the staggered billing cycle for contract holders under Plan 65. To acquire the total required income of $6,889,065, it was computed that the existing rate would have to be increased by $1.13 per month from $7.15 to $8.28 for the 1972-73 rate year. It appears that the total dollar increase in premiums under the projected rate amounts to $937,348, two thirds of which is designed to restore and rebuild reserves for this line of business.

Mr. Adae’s testimony is in substance as follows. Prior to the advent of Medicare in 1966, premiums paid by members contained a factor which was allocated to direct-pay subscribers, part' of which factor served to subsidize the large number of direct-pay elderly members. When Medicare began in 1966, the concept was that it had assumed the burden and responsibility for protection of the elderly. Medicaid by the state was also provided for elderly citizens who could not afford medical coverage. To avoid continued subsidizing of elderly citizens in light of the enactment of Medicare and Medicaid, the decision was made that Plan 65 should stand on its own. Mr. Adae also testified that basic Blue Cross and Blue Shield and Plan 65 were in competition with commercial companies.

Counsel for the Rhode Island Consumers Council was present at the hearing and participated therein. Evidence' in opposition to the application was presented from representatives of señior citizens’ groups. The substance of their testimony is that'they opposed any increase in Plan 65 *169 premiums because many of the elderly could not afford them.

In his decision respondent noted that the total dollar increase under the projected rate amounts to $937,348, two thirds of which was designed to restore and rebuild reserves for the Plan 65 line of business. It appears from the information presented at the hearing before respondent that of the $937,348 total proposed revenue to be produced by new rates, $607,643 was designed to increase Plan 65’s reserve — its surplus — to a level deemed desirable by petitioner’s boards of directors. Only the balance of $329,705 was designed to cover costs of increased patient benefits and higher administrative costs.

The respondent considered initially the portion of the rate request designed to produce sufficient premiums to meet the expected claims on a dollar-to-dollar basis. After discussing the projections made by the proposed plans, such as increase in membership, the increased number of claims, fee increases by physicians, and the claims handling expenses required by the plans to handle the increased enrollment and increased utilization, respondent noted that allowance of all of those items would raise the projected income of the plan from $5,951,000 to $6,281,000, and, barring any unforeseen occurrence, would keep Plan 65 oh a -self-sustaining basis.

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Cite This Page — Counsel Stack

Bluebook (online)
308 A.2d 489, 112 R.I. 164, 1973 R.I. LEXIS 968, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hospital-service-corp-of-rhode-island-v-west-ri-1973.