Kondell v. Blue Cross & Blue Shield of Florida, Inc.

187 F. Supp. 3d 1348, 2016 U.S. Dist. LEXIS 91838, 2016 WL 3554922
CourtDistrict Court, S.D. Florida
DecidedMay 9, 2016
DocketCASE NO. 0:15-CV-61118-ROSENBERG/BRANNON
StatusPublished
Cited by2 cases

This text of 187 F. Supp. 3d 1348 (Kondell v. Blue Cross & Blue Shield of Florida, Inc.) is published on Counsel Stack Legal Research, covering District Court, S.D. Florida primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Kondell v. Blue Cross & Blue Shield of Florida, Inc., 187 F. Supp. 3d 1348, 2016 U.S. Dist. LEXIS 91838, 2016 WL 3554922 (S.D. Fla. 2016).

Opinion

ORDER GRANTING DEFENDANT’S MOTION TO DISMISS

ROBIN L. ROSENBERG, UNITED STATES DISTRICT JUDGE

THIS CAUSE is before the Court on Defendant Blue Cross and Blue Shield of Florida, Inc.’s Motion to Dismiss Plaintiffs’ Amended Complaint [DE 27].1 The Court has carefully considered Defendant’s Mo[1350]*1350tion to Dismiss, Plaintiffs2 Response [DE 40], Defendant’s Reply [DE 46], and Plaintiffs Sur-Reply [DE 49]. In addition, the Court held a hearing on Defendant’s Motion to Dismiss on April 7, 2016, and is otherwise fully advised in the premises. For the reasons set forth below, Defendant’s Motion to Dismiss is GRANTED and Plaintiffs Amended Complaint [DE 16] is DISMISSED WITH PREJUDICE.

I. INTRODUCTION

This is a dispute between Janie Kondell (“Plaintiff’), a woman diagnosed with Hepatitis C more than a decade ago, and her insurer, Blue Cross and Blue Shield of Florida, Inc. (“Defendant”), arising from the denial of Plaintiffs request that Defendant cover the cost of a breakthrough drug called Harvoni. At the center of this dispute are certain guidelines—referred to but not set forth in Plaintiffs insurance policy—pursuant to which Defendant makes decisions regarding Harvoni coverage. While Plaintiff concedes that she did not qualify for coverage under these guidelines at the time her request for coverage was denied, Plaintiff challenges the development and implementation of these guidelines in the first place.

Plaintiff alleges—on her own behalf and on behalf of a putative class—that the development and implementation of these guidelines constitute a breach of contract, a breach of the implied covenant of good faith and fair dealing, and multiple violations of the Racketeer Influenced and Corrupt Organizations Act, 18 U.S.C. § 1961 et seq. (“RICO”). Essentially, Plaintiffs claims are grounded in the allegation that Defendant—acting in concert with others—has used these guidelines to substitute cost for medical necessity as the basis for its decisions regarding Harvoni coverage, despite Defendant’s contractual obligation to cover any treatment that is medically necessary and its continued representations that medical'necessity is its sole consideration.

Guided by the allegations in Plaintiffs Amended Complaint, the terms of the insurance policy attached to Plaintiff’s Amended Complaint, Florida law, and certain legal principles governing the relationship between federal law and state insurance law, the Court concludes that Plaintiffs claims must be dismissed with prejudice.

II. BACKGROUND3

Plaintiff Janie Kondell was diagnosed with Hepatitis C, a progressive liver disease, in 2006. Am. Compl., DE 15 ¶¶ 35-36. In October of 2014, the U.S. Food and [1351]*1351Drug Administration (“FDA”) approved Harvoni, a medication taken once daily in pill form, for the treatment of Hepatitis C. Id. ¶5. In February of 2015, Plaintiffs physician recommended that she begin taking Harvoni and requested prior authorization for the medication from Plaintiffs insurer, Defendant Blue Cross and Blue Shield of Florida, Inc. Id. ¶ 67. That request was denied. Id. .

, A. Plaintiffs Policy

At the time, Plaintiff was insured by Defendant under the BlueOptions Everyday Health 1416 policy (“Plaintiffs Policy”). Id. ¶24. Pursuant to the terms of Plaintiffs Policy, Defendant provides coverage for a Health Care Service or Prescription Drug only if all coverage criteria listed in the Policy are met. See Plaintiffs Policy, DE 15-1 at 15 (listing the coverage criteria for Health Care Services under the heading “WHAT IS COVERED?”); id. at 39 (listing the coverage criteria for Prescription Drugs under the heading- “PRESCRIPTION DRUG PROGRAM”); see also id. at 124 (defining “Health Care Services”); id. at 131 (defining “Prescription Drug”). Among other requirements, a Health Care Service or Prescription Drug must be both “Medically Necessary” and, under certain circumstances, authorized for coverage in advance. See id: át 15, 39.

1. Medically Necessary

With respect to the requirement that a Health Care Service or Prescription Drug be “Medically Necessary,” Plaintiffs Policy includes numerous references to: (1) the definition of “Medically Necessary” set forth in the “DEFINITIONS” section of the Policy; (2) the “MEDICAL NECESSITY” section of the Policy; (3) Defendant’s application of certain additional coverage and payment guidelines in effect at the time a coverage decision is made; and (4) Defendant’s exclusive authority to determine whether or not a particular Health Care Service or Prescription Drug is “Medically Necessary” for coverage purposes.

For example, within the “WHAT IS COVERED?” section, Plaintiffs Policy clarifies that a Health Care Service rmust be Medically Necessary “as defined in this Contract and determined by us [Defendant] in accordance with our Medical Necessity coverage criteria in. effect at the time Services are provided or authorized.” See id. at 15. On the same page, Plaintiffs Policy explicitly states that “[a]ll benefits for Covered Services are subject to ... our Medical Necessity guidelines then in effect (see the MEDICAL NECESSITY and BLUEPRINT FOR HEALTH PROGRAMS sections).” See id.

The “MEDICAL NECESSITY” section, in turn, notes: “In order for, Health Care Services to be covered under this Contract, the Services must meet all of the requirements to be a Covered . Service, including being Medically Necessary, as [1352]*1352determined by us [Defendant] and defined in this Contract.” See id. at 59. That section goes on to state: “In applying the definition of Medical Necessity to a specific Service, we [Defendant] may apply our coverage and payment guidelines then in effect.” See id. That section concludes by suggesting that the insured “refer to the .DEFINITIONS section for the definition of “Medically Necessary or Medical Necessity.” See id.

, Finally, the definition of “Medically Necessary,” set forth in the DEFINITIONS section of Plaintiffs Policy, includes the following statement: “In applying the definition of medical necessity in this Contract, we [Defendant] may apply our coverage and payment guidelines then in effect.” See id. at 126-27;

With respect to Defendant’s authority, referred to throughout Plaintiffs Policy, to determine whether or not a particular Health Care Service or Prescription Drug is “Medically Necessary” for coverage purposes, the limits of such authority are explained as follows:

[A]ny review of medical necessity by us [Defendant] is solely for the purpose of determining coverage or benefits under this Contract and not for the purpose of recommending or providing medical care.... Any such review ... is strictly for the purpose of determining, among other’ things, whether a Service provided or proposed meets the definition of medical necessity in this Contract as determined by us.... You are free to obtain a. Service even if we deny coverage because the Service is not medically necessary; however, you will be solely responsible for paying for the Service.

See id. at 127; see also id. at 59.

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Cite This Page — Counsel Stack

Bluebook (online)
187 F. Supp. 3d 1348, 2016 U.S. Dist. LEXIS 91838, 2016 WL 3554922, Counsel Stack Legal Research, https://law.counselstack.com/opinion/kondell-v-blue-cross-blue-shield-of-florida-inc-flsd-2016.