Massachusetts Ass'n of Older Americans v. Commissioner of Insurance

471 N.E.2d 1281, 393 Mass. 404, 1984 Mass. LEXIS 1835
CourtMassachusetts Supreme Judicial Court
DecidedNovember 29, 1984
StatusPublished
Cited by9 cases

This text of 471 N.E.2d 1281 (Massachusetts Ass'n of Older Americans v. Commissioner of Insurance) is published on Counsel Stack Legal Research, covering Massachusetts Supreme Judicial Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

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Massachusetts Ass'n of Older Americans v. Commissioner of Insurance, 471 N.E.2d 1281, 393 Mass. 404, 1984 Mass. LEXIS 1835 (Mass. 1984).

Opinion

Abrams, J.

The Massachusetts Association of Older Americans, Inc. (MAOA), seeks review of a decisiori of the Commissioner of Insurance (commissioner) approving an increase, effective July 1, 1983, in rates charged by Blue Cross of Massachusetts, Inc. (Blue Cross), and Blue Shield of Massachusetts, Inc. (Blue Shield),2 to persons who subscribe to their “Medex” program. Medex is a form of health insurance which provides supplemental coverage to Medicare beneficiaries (primarily persons age sixty-five and over) for hospital, medical and other health care services which are not covered, or are covered only in part, by Medicare.3

On appeal, MAO A contends that the new Medex rates approved by the commissioner are excessive, in violation of G. L. c. 176A, § 6, and G. L. c. 176B, § 4. Specifically, MAOA argues that the commissioner erred (1) in excluding an external generic drug reduction factor from rate computation; (2) in failing to adjust the proposed rates to reflect the impact of two changes in Federal Medicare law on Medex costs; and (3) in including in the rate calculation a factor for subscriber [406]*406contribution to general reserves. It also challenges as unfairly discriminatory the commissioner’s tentative approval of a schedule of surcharges to be applied to the Medex premiums paid by persons who enroll in the program after their first year of eligibility.4 Finally, MAOA asserts that the revised rates could not lawfully take effect until after August 30, 1983, the date on which the commissioner affirmed the hearing officer’s decision, and that Medex subscribers are thus entitled to a rebate for increased rates paid prior to that date. We conclude that the commissioner’s decision should be upheld, and that the revised rates properly became effective on July 1, 1983.

On March 7, 1983, Blue Cross and Blue Shield filed proposed Medex rates with the Division of Insurance (division), seeking a composite increase in rates of 29.1%, tobe effective June 1, 1983. See G. L. c. 176A, §§ 6 and 10; G. L. c. 176B, § 4. The filing was later revised, and the requested increase reduced to 22.3%. Blue Cross and Blue Shield, MAOA, the division, and the Attorney General participated in a public hearing beginning on April 11, 1983, and lasting eight and one-half days. On June 8, 1983, a deputy commissioner sitting as a hearing officer, see G. L. c. 26, § 7, issued her findings and order approving the revised Medex rates effective July 1, 1983, one month later than Blue Cross and Blue Shield had requested.

The Attorney General and MAOA, pursuant to G. L. c. 26, § 7, appealed to the commissioner, who, on August 30, 1983, issued a detailed decision both affirming the deputy commissioner’s approval of the requested rate revision, and specifically endorsing the effective date of July 1, 1983. Further appeal was filed by MAOA under G. L. c. 176A, § 6, and G. L. [407]*407c. 176B, § 17.5 A single justice of this court allowed a motion by Blue Cross and Blue Shield to intervene as defendants and reserved and reported the appeal for decision by the full court.

1. Standard of Review.

Because our review is premised upon the commissioner’s proper exercise, in the first instance, of his statutory authority, we comment briefly on the scope of that authority. The commissioner does not fix Medex rates; he retains the power to review proposed rates but not to set them. See G. L. c. 176A, §§ 6, 10; G. L. c. 176B, § 4. Contrast G. L. c. 175, § 113B (commissioner shall fix and establish automobile insurance rates). The commissioner may not approve proposed rates which are “excessive, inadequate or unfairly discriminatory.” G. L. c. 176A, § 6, as amended through St. 1984, c. 199, § 2. See G. L. c. 176A, § 10; G. L. c. 176B, § 4. “[H]e may not require that they be at the figures he finds reasonable. Necessarily there is a range of reasonableness and the statute[s] permit disapproval only if the Commissioner finds [the rates] to be outside that range.” Massachusetts Medical Serv. v. Commissioner of Ins., 344 Mass. 335, 339 (1962).6 Moreover, “[t]he burden of furnishing evidence to enable the Commissioner to establish a range of reasonableness is on the insurers.” [408]*408Liberty Mut. Ins. Co. v. Commissioner of Ins., 366 Mass. 35, 42 (1974). Cf. Workers’ Compensation Rating & Inspection Bureau v. Commissioner of Ins., 391 Mass. 238, 245 (1984) (burden of proof on insurers to show that workmen’s compensation rates fall within range of reasonableness); Travelers Indem. Co. v. Commissioner of Ins., 362 Mass. 301, 305 (1972) (burden on automobile insurers to support rates).* *****7

Our review of the commissioner’s decision is governed both by G. L. c. 176A, § 6, and G. L. c. 176B, §§ 12, 17.8 We examine those provisions in turn.

General Laws c. 176A, § 6, mandates public hearings after which “legal rights ... of specifically named persons” (Blue Cross) are determined. Borden, Inc. v. Commissioner of Pub. Health, 388 Mass. 707, 716, cert. denied sub nom. Formaldehyde Inst., Inc. v. Frechette, 464 U.S 936 (1983). Those hearings are thus “adjudicatory proceedings” within the scope of G. L. c. 30A, § 1 (1), as amended by St. 1966, c. 497. See Borden, Inc., supra. See also Newton v. Department of Pub. Utils., 339 Mass. 535, 542 (1959). Cf. Associated Indus. v. Commissioner of Ins., 356 Mass. 279, 284-285 (1969). In reviewing proceedings under G. L. c. 176A, § 6, then, we are directed to the standards set forth in G. L. c. 30A, § 14 (7), and, consequently, we will not disturb the commissioner’s decision unless it is “[unsupported by substantial evidence.”9

[409]*409Because G. L. c. 176B, §§ 12, 17, grant a right to review without specifying a standard,10 our review “in these cases is limited to whether the evidence reasonably supports [the commissioner’s] findings that the rates” were within the “range of reasonableness.” Workers’ Compensation Rating & Inspection Bureau v. Commissioner of Ins., supra at 245. See, Insurance Co. of N. Am. v. Commissioner of Ins., 327 Mass. 745, 752-753 (1951). See generally Swan v. Superior Court, 222 Mass. 542, 546-548 (1916).11 “Reasonable support in the evidence” and “substantial evidence” are not “meaningfully” different. Workers’ Compensation Rating & Inspection Bureau, supra at 244-245. In these circumstances, then, the standard of review required under G. L. c. 176B, §§ 12, 17, is substantial evidence, the same as that under G. L. c. 176A, § 6.

2. Approval of Rates.

a. Medex rate setting methodology. Rates for Medex insurance are set using a variant on the “conventional method” which acknowledges the nonprofit status of Blue Cross and [410]*410Blue Shield. Cf. Attorney Gen. v. Commissioner of Ins., 370 Mass. 791, 796-797 (1976). An allowance for losses is determined by projecting for each Medex benefit the expected cost and frequency of claims. These projections are typically extrapolated from trends in historical (“internal”) data, derived from actual Medex experience.

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471 N.E.2d 1281, 393 Mass. 404, 1984 Mass. LEXIS 1835, Counsel Stack Legal Research, https://law.counselstack.com/opinion/massachusetts-assn-of-older-americans-v-commissioner-of-insurance-mass-1984.