In re Blue Cross

296 N.E.2d 305, 34 Ohio Misc. 29, 63 Ohio Op. 2d 173, 1972 Ohio Misc. LEXIS 150
CourtCourt of Common Pleas of Ohio, Franklin County, Civil Division
DecidedDecember 12, 1972
DocketNo. 72CV-09-2988
StatusPublished
Cited by4 cases

This text of 296 N.E.2d 305 (In re Blue Cross) is published on Counsel Stack Legal Research, covering Court of Common Pleas of Ohio, Franklin County, Civil Division primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
In re Blue Cross, 296 N.E.2d 305, 34 Ohio Misc. 29, 63 Ohio Op. 2d 173, 1972 Ohio Misc. LEXIS 150 (Ohio Super. Ct. 1972).

Opinion

Weight, J.

This is an appeal from an order of the superintendent of insurance denying Blue Cross of Central Ohio a rate increase, pursuant to its application filed under E. C. 1739.051, with respect to a certain class of subscribers. Blue Cross filed a request for a rate increase in June of 1972. A public hearing was held on August 9 and 10, 1972, at which time Blue Cross presented an extensive amount of testimony dealing with the necessity, reasonableness, and fairness of its proposed rate increase. Following this hearing the superintendent of insurance under date of September 7, 1972, denied approval to the Blue Cross application for a change of rates. The full content of the superintendent’s letter follows:

[30]*30“September 7, 1972
“Blue Cross of Central Ohio
174 East Long Street
Columbus, Ohio 43215
“Attention: Mr. Howard C. Franz, President
“Dear Mr. Franz:
“The staff of the Department of Insurance and its professional consultants have reviewed the record made at the public hearings of August 9 & 10, 1972, regarding your proposed rate increase for direct paying subscribers. We have also reviewed your initial proposal and the supporting data supplied by your office.
“We find initially that we cannot agree with your use of certain data in the calculation of the proposed rate increase. To support the requested increase Blue Cross relied extensively on the experience of large group subscribers, which experience is not truly representative of the experience which emerges from direct pay subscribers. Such direct pay experience data was available to Blue Cross and should have been used to a greater extent in the calculation of this rate.
“We have further determined that the direct pay group is unfairly and adversely affected by the disproportionate loss experience resulting from Blue Cross’ practice of transferring latent claims of former group subscribers into the direct pay category. We believe that Blue Cross can implement a procedure which will offset this adverse factor and thereby result in a favorable adjustment to the direct pay experience data.
“We further find that Blue Cross has failed to exert any effective influence over its member hospitals to operate more efficiently and has thereby failed to shed its traditionally paternalistic attitude toward the hospitals and assume the position of vigorously representing the interests of its subscribers. Blue Cross has the duty of seeing that its subscribers obtain the best health care possible for their dollar by making every effort to compel member hospitals to effect economies and to monitor utilization.
“We, therefore, for the above reasons and in consider[31]*31ation of all the data and factors involved in the request for approval of the proposed rate increase, find that said proposal is other than fair, lawful, and reasonable and is not supported by sufficient, relevant and material evidence which would justify our approval at this time. The request for approval is therefore denied.
“Sincerely,
“KENNETH E. DeSHETLEE
“Director of Insurance
“/s/ E. E. Eckert
“Deputy Director”

Both parties requested that they be allowed to present testimony supplementing the record of the proceedings of August 9 and 10. The requests were granted and the court heard extensive testimony on November 17 and November 22. During the course of the aforementioned supplementary proceedings, the superintendent, through its counsel, withdrew the content contained in the second and third paragraph of the superintendent’s letter of September 7,1972, as grounds for denying the Blue Cross application for a change of rates, thus narrowing the issues in the case to the grounds contained in paragraph 4 of the aforementioned letter. The superintendent, both through his counsel and on the record, asserts that the department of insurance has both the right and the duty to protect Blue Cross subscribers from increased rates due to higher than necessary hospital costs accrued by hospitals doing business with Blue Cross and member hospitals under the contractural relationship as evidenced by the Supplementary exhibits A and B presented by Blue Cross. The superintendent asserts that Blue Cross has failed to properly police and control these costs and therefore a rate increase must be denied. The superintendent concedes by withdrawing the first two grounds for his denial of the rate increase that the change of rates is both necessary, reasonable and fair from an actuarial standpoint, but urges that the alleged failure of Blue Cross, as aforementioned, provides a proper and lawful base for promulgating a broad sweeping rule via a rate adjudication.

[32]*32The state cites the case of S. E. C. v. Chenery Corp., 332 U. S. 194, in support of its proposition that the superintendent is entitled to, in effect, make a rule by adjudication. In this case, the appellee argued that at the time the commission made its decision, the S. E. C. had no rule or regulation on which the order was based and that the S. E. C. could regulate only by clearly announced regulations of perspective effect. While the Ghenery case is most certainly distinguishable upon its facts from the case at bar, it does in fact stand for the proposition enunciated by the United States Supreme Court, at page 202 of that opinion:

“In other words, problems may arise in a case which the administrative agency could not reasonably foresee, problems which must be solved despite the absence of a relevant general rule. Or the agency may not have had sufficient experience with a particular problem to warrant rigidifying its tentative judgment into a hard and fast rule. Or the problem may be so specialized and varying in nature as to be impossible of capture within the boundaries of a general rule. In those situations, the agency must retain power to deal with the problems on a case-to-case basis if the administrative process is to be effective. There is thus a very definite place for the case-by-case evolution of statutory standards. And the choice made between proceeding by general rule or by individual, ad hoc litigation is one that lies primarily in the informed discretion of the administrative agency.”

The court goes on to uphold the acts of the commission. This court would concede that this case seems to support the general posture adopted by the superintendent; however, there are two principal points that occur to this court in holding that this case is inapplicable to the situation at bar. In the majority opinion, the court makes reference to the fact that they had previously affirmed the reversal of the action of the S. E. C. They stated the following at page 196:

“When the case was first here, we emphasized a simple but fundamental rule of administrative law. That rule is [33]

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Related

New Hampshire-Vermont Hospitalization Service v. Whaland
315 A.2d 191 (Supreme Court of New Hampshire, 1974)
In Re Application
319 N.E.2d 212 (Ohio Court of Appeals, 1973)
Blue Cross v. Supt. of Ins.
40 Ohio App. 2d 285 (Ohio Court of Appeals, 1973)
New Hampshire-Vermont Physician Service v. Durkin
313 A.2d 416 (Supreme Court of New Hampshire, 1973)

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Bluebook (online)
296 N.E.2d 305, 34 Ohio Misc. 29, 63 Ohio Op. 2d 173, 1972 Ohio Misc. LEXIS 150, Counsel Stack Legal Research, https://law.counselstack.com/opinion/in-re-blue-cross-ohctcomplfrankl-1972.