Morgan v. Blue Cross & Blue Shield of Kentucky, Inc.

794 S.W.2d 629, 1989 WL 153645, 1989 Ky. LEXIS 116
CourtKentucky Supreme Court
DecidedDecember 21, 1989
DocketNos. 89-SC-146-TG, 89-SC-152-TG
StatusPublished
Cited by4 cases

This text of 794 S.W.2d 629 (Morgan v. Blue Cross & Blue Shield of Kentucky, Inc.) is published on Counsel Stack Legal Research, covering Kentucky Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Morgan v. Blue Cross & Blue Shield of Kentucky, Inc., 794 S.W.2d 629, 1989 WL 153645, 1989 Ky. LEXIS 116 (Ky. 1989).

Opinions

WINTERSHEIMER, Justice.

This appeal is from a judgment of the Franklin Circuit Court which reversed an order of the Commissioner of the Kentucky Department of Insurance which had disapproved certain rate filings submitted by Blue Cross and Blue Shield of Kentucky, Inc. on three direct-pay lines of health insurance. The circuit court judgment also dismissed a counterclaim by the Kentucky Attorney General which sought to have the rate filings disapproved on other grounds.

More than 46,000 families were affected by the rate filings: 10,314 in conversion coverage; 29,225 in farm bureau and 6,480 in nongroup. These policyholders are those without the opportunity for group coverage through an employer, union or other association to bargain and pay premiums on their behalf. These subscribers consist largely of small business people, family farmers, early retirees, unemployed individuals, those who lost coverage due to divorce or death of a spouse and single parents working at low-paying or part-time jobs. In conjunction with the over-all increases, Blue Cross also sought to implement demographic ratings in the farm bureau and nongroup coverages. The result was that policyholders in the age categories from 60 to 64 faced rate increases of approximately 80 percent.

The Commissioner of Insurance ordered public hearings but announced that the hearings would be held under KRS 304.12-130. The hearing officer received testimony from actuarial experts, complaints of consumers, etc., and determined by final order that the increase of approximately 40 percent for three lines of coverage was an unfair practice and not in the public interest in violation of KRS 304.12-130. The Commissioner also found that Blue Cross had failed to carry its burden concerning the filings by failing to provide complete information on its operating expenses pursuant to 806 KAR 17:070 Sec. 4(2)(b)(5). At least part of this failure can be attributed to the fact that the Commissioner failed to comply with the statutory requirements contained in 304.12-130 — viz., “(1) If the Commissioner believes that any person engaged in the insurance business is engaging in this state in any method of competition or in any act or practice in the conduct of such business which is not defined in this subtitle but that such method of competition is unfair, deceptive or not in the public interest, or that such act or practice is unfair or deceptive and that a proceeding by him in respect thereto would be in the public interest, he shall, after a hearing of which notice of the hearing and of the charges against him are given such person, make a written report of his findings relative to such charges and serve a copy thereon upon such person and any inter-venor at the hearing.” This was not done, and will be discussed later in the opinion.

The Commissioner ordered Blue Cross to cease the implementation of its rate increases and to refund premiums collected because of the increases. It should be further noted that KRS 304.12-130 makes no provision for refund of premiums collected.

Blue Cross appealed to the Franklin Circuit Court, which set aside an order of the Commissioner and stated that the action of the Commissioner was in excess of the statutory power of the Commissioner. This appeal followed.

Blue Cross provides health care coverage for approximately 539,000 policyholders in [631]*631Kentucky representing over 1,125,000 persons by various policies and is Kentucky’s largest provider of health care insurance with approximately 30 percent of the market. Blue Cross has a very large number of subscribers in the 60-64 age group. As people age, they use proportionately more medical services thereby causing the insurer to be responsible for ever increasing outlays of funds to provide such services. Blue Cross made a decision, at the corporate level, to change their rate structure to one of actuarially sound demographic based computations. In the past several years, Blue Cross has implemented the age/sex ratings so as to reduce the over-all average age. The current request would cause the average age to fall into the 40’s which would in the company’s opinion stabilize their business. In the past several years, Blue Cross has lost in excess of $6 million on lines of insurance provided to the elderly. Their reserves have been reduced from $189 million to $100 million. Unfortunately the older consumer of health care with health problems has no other feasible source of health insurance. In some cases they must pay the 81 percent increase or abandon their coverage during the time of their life when health care is most important.

The company, the Department of Insurance and the public all have a significant stake in the cost and availability of health insurance.

The judgment of the circuit court that the trade practice provisions of the Kentucky Insurance Code do not apply to individual health insurance rate filings is erroneous, and is reversed. The General Assembly has not exempted rate filings from the trade practices act in regard to individual health insurance rate filings, nor provided in KRS 304.12-130 that rate filings are subject to that statute. However, it is the opinion of this court that the Franklin Circuit Court was erroneous in determining that KRS 304.12-130 did not apply to individual rate filings.

The Commissioner found that the manner in which the rate increases were implemented in conjunction with the imposition of full demographic rating is unfair and not in the public interest in violation of KRS 304.12-130, without stating in what way it was unfair and not in the public interest. There is no statutory definition of the terms “unfair” and “not in the public interest” in regard to these insurance statutes, nor is there a judicial definition on the books.

KRS 304.14-130(l)(d) authorizes disapproval of individual health insurance rates if the benefits provided are unreasonable in relation to premium charge and loss ratios. The Commissioner has adopted 806 KAR 17:070 and defined reasonableness of benefits in relation to premium charge and loss ratios. The anticipated loss ratio necessary to meet the standard of reasonableness for the rate filing in question is 55 percent. 806 KAR 17:070 § 5(2). However, the guideline established by the regulation is not automatic. 806 KAR 17:070 § 4(2)(b)(5) requires a brief description of how the revised rates were determined, including a general description and source of each assumption.

The company failed to provide timely information on its cost allocation procedures, which, as we have said, is explained at least in part by the fact that the company was not notified that the hearing was proceeding under any statute which required cost allocation proceedings.

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

Related

Hinkle v. Commonwealth
104 S.W.3d 778 (Court of Appeals of Kentucky, 2002)
Commonwealth Ex Rel. Chandler v. Anthem Insurance Companies
8 S.W.3d 48 (Court of Appeals of Kentucky, 1999)
Southeastern United Medigroup, Inc. v. Hughes
952 S.W.2d 195 (Kentucky Supreme Court, 1997)

Cite This Page — Counsel Stack

Bluebook (online)
794 S.W.2d 629, 1989 WL 153645, 1989 Ky. LEXIS 116, Counsel Stack Legal Research, https://law.counselstack.com/opinion/morgan-v-blue-cross-blue-shield-of-kentucky-inc-ky-1989.