Humana, Inc. v. Castillo

728 So. 2d 261, 1999 WL 13003
CourtDistrict Court of Appeal of Florida
DecidedJanuary 15, 1999
Docket98-01992
StatusPublished
Cited by38 cases

This text of 728 So. 2d 261 (Humana, Inc. v. Castillo) is published on Counsel Stack Legal Research, covering District Court of Appeal of Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Humana, Inc. v. Castillo, 728 So. 2d 261, 1999 WL 13003 (Fla. Ct. App. 1999).

Opinion

728 So.2d 261 (1999)

HUMANA, INC., a Delaware corporation, Humana Medical Plan, Inc., a Florida corporation f/d/b/a Humana Health Plan Of Florida, Inc.; and Humana Health Plan Of Florida, Inc., Appellants,
v.
Israel CASTILLO, Lorenzo Ruiz, Irene Breitenfeld, Hiram Mott, and Ralph Philpot, Appellees.

No. 98-01992.

District Court of Appeal of Florida, Second District.

January 15, 1999.
Rehearing Denied March 8, 1999.

*262 Edward M. Waller, Jr., Hala A. Sandridge, and Elizabeth A. Boland of Fowler, White, Gillen, Boggs, Villareal & Banker, P.A., Tampa, for Appellants.

Jonathan L. Alpert, William J. Cook and David Ferrentino of Alpert, Barker & Rodems, P.A., Tampa, for Appellees.

CAMPBELL, Acting Chief Judge.

Appellants (Humana) challenge the trial court order finding that appellees' action against Humana qualified as a class action suit. We reverse.

Appellees brought this action for rescission and damages allegedly arising from their enrollment in appellants' (Humana) Gold Plus Plan, a Medicare health maintenance organization (HMO). Appellees allege that Humana misrepresented and/or failed to disclose the terms of its arrangements with physicians, particularly its affiliated primary care physicians (PCPs). Specifically, appellees claim Humana misrepresented and/or failed to disclose:

1. that PCPs were paid a flat rate per member per month (capitation) by Humana for the care of members;
2. that Humana had financial arrangements with PCPs which allegedly created an incentive not to treat or not to refer to a specialist;
3. that Humana allegedly required PCPs to obtain authorization from Humana before admitting a member to a hospital and before discussing with a member the possibility of hospitalization;
4. that Humana's contracts with PCPs allegedly contained "gag" clauses, which restricted the physicians' ability to discuss treatment options with members; and
5. that members were "locked in" to Humana providers.

The complaint further alleges that appellees' PCPs failed to provide necessary referrals to specialists or failed to order indicated tests as a result of their financial arrangements with Humana.

Appellees allege claims for fraud, unjust enrichment, and money had and received. All three counts are premised upon the theory that Humana allegedly misrepresented or failed to disclose the above-referenced information to potential enrollees in the plan. Appellees sought rescission and damages under all three counts.

In their complaint, appellees sought to represent a class of all individuals who, between *263 1987 and 1997, enrolled in the Humana Gold Plus Plan. Appellees filed a motion to have the class certified pursuant to Florida Rule of Civil Procedure 1.220, and Humana opposed the motion. An evidentiary hearing was held on the class certification motion, and the trial court heard from four purported class representatives and four putative class members. These individuals placed different levels of importance on information allegedly withheld and the HMO's financial arrangements with its affiliated physicians. Some of the individuals testified that such information would not have affected their decisions to enroll and did not affect their decisions to remain enrolled. Others testified that had they known about financial arrangements, they would not have enrolled. These same individuals have each enrolled with another Medicare HMO and, in spite of the fact that they then were aware of such arrangements, they failed to inquire about that HMO's arrangements with its physicians. One class representative and one witness affirmatively stated the financial arrangements between Humana and its doctors was "none of [their] business." Another individual testified that had he known about the arrangements, he would not have enrolled; and, now that he is a Medicaid recipient, he has not enrolled with another HMO.

Given this testimony, Humana argued that under prevailing Florida law the class could not be certified under rule 1.220 because a class action was unsuitable for fraud actions, citing Lance v. Wade, 457 So.2d 1008 (Fla. 1984) (holding that the class action device was inappropriate for fraud actions). Consistent with the Lance analysis, Humana argued that issues common to the class did not predominate over individual issues and that a trial would devolve into a series of mini-trials as to whether each individual class member would have enrolled in the Humana Gold Plus Plan even if the omitted information had been disclosed.

Appellees responded that a class action was appropriate because this was an "omissions" case, not a fraudulent misrepresentation case, and that in an omission case the reliance prong need not be proved. The trial court agreed with appellees' argument and certified the class. The trial court, primarily relying on out-of-state authorities, attempted to distinguish Lance on the basis that the fraud in Lance involved active misrepresentations rather than fraud by "omission," as alleged in this case.

Appellees' complaint alleges that Humana fraudulently induced them and the class into joining the Gold Plus Plan by failing to disclose material information to them and, in particular, failing to disclose the following material facts while marketing its Medicare HMO:

• A member's primary care physician would receive the same fixed fee from Humana regardless of the treatment required or desired, and the primary care physician would therefore make more money for less treatment provided to the member;
• The primary care physician bore the costs of specialty consultations, diagnostic testing, hospital admission, or other health care services and thus had no incentive to prescribe these services;
• Humana's agreements with primary care physicians created a financial incentive to provide absolutely no or minimal health care services to the Humana members and a fiscal disincentive to refer members to specialty consultations, diagnostic testing, hospital admissions or other medical services/treatment;
• Primary care physicians had a financial incentive to "carry" as many members as would select a physician, regardless of whether the physician could treat or provide adequate medical services to such a large group of individuals;
• The "gag clauses" in Humana's agreements with its primary care physicians prohibited them from disclosing or advising the member of certain medical treatments Humana would not cover, or did not want to cover, regardless of whether the treatments or procedures might be medically advisable or necessary;
• Humana required its primary care physicians to obtain a pre-admission review before a hospital admission occurred or even before mentioning or conveying the possibility of admission to the member so *264 that such admission could be discouraged, delayed or prevented; and
• If a primary care physician referred a member for specialty care, the member could be "locked in" so that he could only see certain Humana approved specialists.

In appellees' count for fraud in the inducement, they allege that Humana used these omissions to perpetuate a fraud on appellees and the class. Appellees argue that each class member reasonably and justifiably relied on the information Humana provided them, which did not

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Cite This Page — Counsel Stack

Bluebook (online)
728 So. 2d 261, 1999 WL 13003, Counsel Stack Legal Research, https://law.counselstack.com/opinion/humana-inc-v-castillo-fladistctapp-1999.