Lifeline Ambulance, Inc. v. Iowa Insurance Division

505 N.W.2d 186, 1993 Iowa Sup. LEXIS 197, 1993 WL 327228
CourtSupreme Court of Iowa
DecidedAugust 25, 1993
Docket92-1534
StatusPublished
Cited by2 cases

This text of 505 N.W.2d 186 (Lifeline Ambulance, Inc. v. Iowa Insurance Division) is published on Counsel Stack Legal Research, covering Supreme Court of Iowa primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Lifeline Ambulance, Inc. v. Iowa Insurance Division, 505 N.W.2d 186, 1993 Iowa Sup. LEXIS 197, 1993 WL 327228 (iowa 1993).

Opinion

CARTER, Justice.

At issue on this appeal is an order of the Iowa Insurance Commissioner upholding action by a health maintenance organization retroactively terminating a group health insurance plan for the employees of appellant, Lifeline Ambulance, Inc. (Lifeline Ambulance). Lifeline Ambulance urged, both before the agency and in the district court, that the attempted termination of the agreement was not properly carried out because the employee-members of the plan had not received notice as required by statute. The proceeding is for review of agency action pursuant to Iowa Code section 17A.19 (1987). The district court upheld the agency decision. We reverse.

The controversy involves an attempt by the intervenor, University Health Care Plan of Iowa, a health maintenance organization organized under Iowa Code chapter 514B (the HMO), to terminate a group contract with Lifeline Ambulance. Thq, basis for the attempted termination of the contract was a default in the payment of premiums due under the plan. On February 2, 1989, the HMO notified Lifeline Ambulance that because of a default in the payment of premium its contract was canceled retroactive to December 31,1988, the date to which premiums were last paid. Later, this notice was revised to provide that cancellation was retroactive to November 30, 1988, because that was in fact the last date to which premiums had been paid.

The HMO gave no notice to the individual employee enrollees under the group contract that their health care benefits were being terminated. It is that circumstance that gives rise to Lifeline Ambulance’s primary contention on appeal that benefits under the plan were not properly terminated. Additional facts material to the issues on appeal will be set forth in our discussion of the points of law raised by the parties.

*188 I. Distinction Between Termination of Group Contract and Termination of Coverage for Individual Employees.

At the outset, we must clarify the conflicting claims of the parties concerning the distinction between termination of the employer’s group contract with the HMO and termination of the coverage for individual employees enrolled under the group plan. We begin this discussion by expressing our belief that these two matters are in fact inseparable. There is no realistic way of viewing the existence of a group medical plan other than through its effect on the members of the group.

Lifeline Ambulance urges, with support in the record, that it is pursuing this challenge as the agent of its employees pursuant to a specific contract clause. Its right to do so was acknowledged by the administrative law judge who heard this matter pursuant to contested case procedure. In determining the merits of the challenge to contract termination, however, both the administrative law judge and the insurance commissioner determined that notice to the employees covered by the plan was not necessary in order to terminate their rights under the group contract.

The administrative law judge appeared to conclude that Lifeline Ambulance’s employees were “enrollees” as defined in section 514B.1(4). He concluded, however, that language contained in Iowa Code section 509B.5(2) (1987) makes the enrollee-notice requirement of section 514B.17 inapplicable to enrollees under group contracts. The administrative law judge ruled that section 509B.5(2) provides that: (1) the employer, rather than the HMO, is to give notice to the employees of termination of the group contract; (2) the HMO’s liability to members of the group ends immediately upon the termination of the group plan (or possibly prior thereto); and (3) until the employer gives notice to the employees that the group contract has been canceled, it remains solely responsible for providing health care benefits under the plan. The insurance commissioner in a brief order stated that the decision of the administrative law judge “is upheld in its entirety.” Language in that order, however, indicates some doubt on the part of the commissioner that Lifeline Ambulance had standing to pursue claims of legal entitlement on the part of its employees.

We conclude that Lifeline Ambulance does have standing to argue that its employees were entitled to notice of termination of benefits under section 514B.17. The group contract makes it the agent of its employees for this purpose. Moreover, due in part to the legal reasoning of the agency and the district court concerning Lifeline Ambulance’s personal liability under section 509B.5(2), it has a personal stake in the impending controversy-

II. Termination of the Group Contract According to its Terms.

Lifeline Ambulance has challenged whether the group contract was properly terminated by the HMO pursuant to its terms. The agency and the district court concluded that it was. On this issue, the controversy centers on the legal consequences of a tender of certain checks by Lifeline Ambulance and the HMO’s refusal to accept those checks.

The group contract between Lifeline Ambulance and the HMO provides that it may be canceled by the latter if Lifeline Ambulance fails to prepay the applicable premium for a period of thirty days. It further provides that “[o]n the occasion of the second default of premium [the HMO] retains the right to refuse acceptance of premium for the period charged and retains the right to cancel group coverage for that reason.” The record reveals that there had been several defaults of premium prior to the HMO’s refusal of Lifeline Ambulance’s checks. This refusal and return of cheeks was accompanied by a written notice purporting to terminate the contract.

Unless otherwise regulated by statute, the parties to an agreement may specify therein circumstances or conditions that empower a party to terminate the contract. Artificial Ice Co. v. Reciprocal Exch., 192 Iowa 1133, 1140, 184 N.W. 756, 759 (1921); Medford v. Pacific Nat’l Fire Ins. Co., 189 Or. 617, 624, 219 P.2d 142, 147 (1950) (absent controlling statute, parties may make such *189 contract as they desii’e concerning method of cancellation); 43 Am.Jur.2d Insurance § 383 (1982). The parties to the present agreement did that. The evidence clearly established that one of the conditions for termination, ie., repeated default of premium, occurred. Lifeline Ambulance has suggested no statute that would preclude the inclusion of this ground of termination in the contract.

We agree with the agency and the district court that the group contract was properly terminated by the HMO in accordance with its terms. For reasons that are set forth in the following division, however, termination of the group contract, although a ground for termination of the rights of the individual employee-enrollees, may not automatically work a termination of those rights. We must also consider the applicability of statutory notice requirements to the employee-enroll-ees.

III. Notice Requirements to Individual Enrollees Under Section 51IB.17.

Lifeline Ambulance argues that irrespective of whether the group policy was terminated according to the contractual language, the rights of the individual enrollees have not been effectively terminated because the HMO failed to give them the notice of termination required by law.

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505 N.W.2d 186, 1993 Iowa Sup. LEXIS 197, 1993 WL 327228, Counsel Stack Legal Research, https://law.counselstack.com/opinion/lifeline-ambulance-inc-v-iowa-insurance-division-iowa-1993.