Kenavan v. Empire blue Cross & Blue Shield

248 A.D.2d 42, 677 N.Y.S.2d 560, 1998 N.Y. App. Div. LEXIS 9484
CourtAppellate Division of the Supreme Court of the State of New York
DecidedSeptember 17, 1998
StatusPublished
Cited by14 cases

This text of 248 A.D.2d 42 (Kenavan v. Empire blue Cross & Blue Shield) is published on Counsel Stack Legal Research, covering Appellate Division of the Supreme Court of the State of New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Kenavan v. Empire blue Cross & Blue Shield, 248 A.D.2d 42, 677 N.Y.S.2d 560, 1998 N.Y. App. Div. LEXIS 9484 (N.Y. Ct. App. 1998).

Opinion

OPINION OF THE COURT

Naírdelli, J.

Plaintiffs paid premiums for Medigap insurance (i.e., coverage for the 20% difference the patient is liable for when a doctor does not accept assignments from Medicare). In so doing, they believed that they would be covered for any difference in the amount paid by Medicare to the doctor and the reasonable amount billed. Defendant Empire failed to live up to its obligations under the policies and breached the insurance contracts. In the words of plaintiff Robert Kenavan at his deposition, “I got a policy that ain’t being lived up to”.

Medicare Part A covers in-patient hospitalization expenses for persons 65 years and/or older and the disabled. Medicare Part B covers certain doctors’ services for the same persons (42 USC § 1395j et seq.). Under Part B, the Federal Supplementary Medical Insurance Trust Fund covers “80 percent of the reasonable charges for the services” after satisfaction of a deductible (42 USC § 1395/ [a] [1]). The Medicare recipient is [44]*44responsible for the other 20% of approved charges (the coinsurance amount). “Participating providers” are doctors who accept assignment of claims directly from Medicare, agreeing to accept the allowable charges in full satisfaction of their bills so the patient is not responsible for any amount. Where doctors choose not to accept assignments (nonparticipating providers), the bill may be in excess of the Medicare-approved charge, subject to a statutory fee cap. While the patient is responsible for the entire bill, he or she may seek reimbursement from Medicare for the 80% that Medicare covers. Thus, Medicare will pay 80% of the “reasonable” charges after satisfaction of the deductible and the patient must pay the remainder. Various insurers offer policies offering supplemental insurance for the “gap” between the 80% of reasonable costs paid by the Federal Government and the 20% that the patient must pay. Hence the term “Medigap” insurance.

In 1985, Congress enacted the Gramm-Rudman-Hollings Act (Gramm-Rudman) to help cut the Federal deficit by requiring automatic deductions (called sequestrations) in certain Federal programs where Congress and the President could not agree on a budget projecting a prescribed reduction. The amounts of the deductions are determined annually in conjunction with the adoption of the Federal budget (see, 2 USC § 900 et seq.). Under these provisions, there have been reductions in Medicare payments of 1% in the period from March 1, 1986 to September 30, 1986; 2.324% in the period between November 21, 1987 and March 31, 1988; 2.092% between October 17, 1989 and March 3, 1990; 1.4% between April 1, 1990 and September 30, 1990; and 2% for the period from November 11, 1990 until December 31, 1990. There have been no Gramm-Rudman deductions since 1990. As part of this legislation, Congress expressly , relieved Medicare patients on assigned claims to participating providers from any liability to their doctors for the Gramm-Rudman reductions in benefits. In effect, the doctors who accepted the assignments were deemed to have accepted payment “less any reduction in payment amount made pursuant to a [Gramm-Rudman] sequestration order, as payment in full” (2 USC § 906 [d] [3]).

The plaintiffs in this class action are beneficiaries under the defendant Empire Blue Cross and Blue Shield’s (Empire) individual supplemental insurance (Medigap) policies who filed unassigned claims under Medicare Part B for benefits from the Federal Government and then from defendant under their Medigap policies for the period from March 1,1986 to December [45]*4531, 1992 and whose benefits were reduced by provisions of Gramm-Rudman. Their claim, in short, is that Empire breached its Medigap insurance contracts with them by failing to increase the benefits to cover the increase in the coinsurance for which they were liable as a result of the reduced Medicare payments under Gramm-Rudman. Thus, plaintiffs allege they were treated by physicians and were told by the Federal Government thereafter that their Medicare Part B benefits had been reduced by the stated amounts for the various periods. When they submitted claims to Empire under their Medigap policies for reimbursement, they did not receive payment for the amounts represented by the Gramm-Rudman reductions, although, they contend, they were entitled to 100% reimbursement under the Medigap policies for the amounts paid by them.

Plaintiffs originally began this action in 1991 in State court. Defendant successfully moved to have it removed to the Federal Court on the ground that the complaint raised a Federal question to the extent that it asserted claims on behalf of members who were covered under employee benefit plans subject to the Employee Retirement Income Security Act of 1974 (ERISA). The Federal District Court dismissed the ERISA claims without prejudice, granted class certification, denied defendant’s motion to dismiss and remanded the State law claims of all remaining non-ERISA class members to the Supreme Court, New York County.

In the order appealed from herein, the IAS Court granted plaintiffs’ motion for summary judgment on the second cause of action for breach of contractual obligations, alleging that Empire failed to reimburse plaintiffs adequately under the express language and intent of its Medigap policies in that Empire refused to pay the deductions in the Medicare payments made as a result of the Gramm-Rudman sequestrations. We affirm.

The policies issued to the various members of the class are basically the same with some minor variations, not essential to the disposition herein. Thus, the Empire Tradition PLUS Medicare Supplement Program policy states that it “fills in * * * coinsurance amounts that Part A and Part B of the Federal Medicare Program do not pay for”. The policy also states, in its general information section: “There are deductible and coinsurance amounts that you must pay and that is where this supplementary coverage helps you meet your bills,” and that “The Medicare benefits described in this Contract * * * can be changed by an Act of Congress.” In a separate policy [46]*46article explaining the extent of benefits supplementing Part B, the Tradition PLUS policy states:

“After you satisfy your Part B deductible, which only applies once each calendar year, Medicare will usually pay you 80 percent of the amount approved as the allowed charge for the service you received. * * *

“We will pay 20 percent of the allowed charge as determined by Medicare after you have satisfied your Medicare Part B deductible. If your bill is higher than the allowed charge, neither Medicare nor we will pay the difference nor will we pay anything if Medicare pays you 100 percent of its allowed charge.”

The Enhanced Medicare Plus policy to which plaintiff Schmookler subscribed contains the same general statements that it “pays 20 percent of all Medicare Part B approved charges”, that it “fills in the deductible and coinsurance amounts that Part A and Part B * * * do not pay for,” and that there can be benefit changes by Act of Congress or when the Federal Government increases the deductible and coinsurance amount. The only difference between this policy and the Tradition PLUS policy is that the latter contains a provision for an automatic premium increase whenever the Federal Government mandates an increase in the deductible or coinsurance amounts. Otherwise all the policies contain similar language. Thus, all of the policies contain language limiting coverage to the patient’s obligation to pay:

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Perella Weinberg Partners LLC v. Kramer
2017 NY Slip Op 6341 (Appellate Division of the Supreme Court of New York, 2017)
National Railroad Passenger Corp. v. Arch Specialty Insurance
124 F. Supp. 3d 264 (S.D. New York, 2015)
Endurance American Specialty Insurance v. Century Surety Co.
46 F. Supp. 3d 398 (S.D. New York, 2014)
Catlin Speciality Insurance v. QA3 Financial Corp.
36 F. Supp. 3d 336 (S.D. New York, 2014)
Santa v. Capitol Specialty Insurance
96 A.D.3d 638 (Appellate Division of the Supreme Court of New York, 2012)
Solar & Environmental Technologies Corp. v. Zelinger
726 F. Supp. 2d 135 (D. Connecticut, 2009)

Cite This Page — Counsel Stack

Bluebook (online)
248 A.D.2d 42, 677 N.Y.S.2d 560, 1998 N.Y. App. Div. LEXIS 9484, Counsel Stack Legal Research, https://law.counselstack.com/opinion/kenavan-v-empire-blue-cross-blue-shield-nyappdiv-1998.