N. Anand v. Com. of PA, PA Ins. Dept.

CourtCommonwealth Court of Pennsylvania
DecidedOctober 11, 2024
Docket318 M.D. 2023
StatusUnpublished

This text of N. Anand v. Com. of PA, PA Ins. Dept. (N. Anand v. Com. of PA, PA Ins. Dept.) is published on Counsel Stack Legal Research, covering Commonwealth Court of Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
N. Anand v. Com. of PA, PA Ins. Dept., (Pa. Ct. App. 2024).

Opinion

IN THE COMMONWEALTH COURT OF PENNSYLVANIA

Neil Anand, : Petitioner : : v. : No. 318 M.D. 2023 : Commonwealth of Pennsylvania, : Submitted: September 9, 2024 Pennsylvania Insurance Department, : Respondent :

BEFORE: HONORABLE RENÉE COHN JUBELIRER, President Judge HONORABLE PATRICIA A. McCULLOUGH, Judge HONORABLE ANNE E. COVEY, Judge

OPINION NOT REPORTED

MEMORANDUM OPINION BY JUDGE McCULLOUGH FILED: October 11, 2024 Neil Anand (Requester) petitions for review of the July 11, 2023 Final Determination of the Office of Open Records (OOR), which denied his appeal from the March 15, 2023 decision of the Pennsylvania Insurance Department (Department) granting in part and denying in part his Right-to-Know Law1 (RTKL) request (Request). Requester also seeks relief in our original jurisdiction in the form of a petition for writ of mandamus and/or petition to enforce pursuant to Pennsylvania Rule of Appellate Procedure (Pa.R.A.P.) 3761(b). The Department has filed preliminary objections to the original jurisdiction portion of Requester’s petition for review, arguing, among other things, that it must be dismissed due to this Court’s lack of jurisdiction. The Department further argues that the OOR’s Final Determination should be affirmed in total. Upon review, we sustain the Department’s preliminary objections in part, dismiss the original jurisdiction portion of the petition for review, and affirm the OOR.

1 Act of February 14, 2008, P.L. 6, 65 P.S. §§ 67.101-67.3104. I. BACKGROUND AND PROCEDURAL HISTORY On March 28, 2023, Requester submitted the Request to the Department seeking 24 categories of records relating to “Independence Blue Cross” and the “Independence Company” or “Independence Companies”2 for the years 2009 through 2019. Specifically, the Request sought: 1. All documents of health insurance premiums, base prices and rate adjustments that were reviewed and/or calculated by [the] Department for individual and small businesses. 2. All documents of reviews or calculations for base rate or price including but not limited to medical costs ([i.e.,] how much and how often), operating costs ([i.e.,] salaries, rent, and marketing), taxes, fees, and profits. 3. All documents of reviews or calculations for rate adjustments including age, location, tobacco use, and family size. 4. All documents of determinations when reviewing rates of medical costs, non-medical costs, and operating costs where the proposed rates were excessive, inadequate, or discriminatory. 5. All documents of determinations when reviewing rates which were not approved by [the Department]. 6. All Independence Company documents pertaining to failure to meet regulatory requirements, requiring rebates to be issued on premiums paid or where premium differences or miscalculations were paid back to insureds. 7. All documents of reviews or calculations of health insurance premiums, base prices[,] and rate adjustments that were reviewed and/or calculated by [the] Department factoring: [(]1) [r]ecovery of payments; [(]2) [r]ecovered [s]avings; [(]3) [c]laims [d]enied; [(]4) [c]laim [r]ecoveries;

2 The Request defined the “Independence Companies” to include “Independence Blue Cross, Inc., Ameri[H]ealth HMO, Inc., Independence Blue Cross, LLC, Independence Health [G]roup, Inc., Independence Hospital Indemnity Plan, Inc., Keystone Health Plan East, Inc., QCC Insurance Company[], and Ameri[H]ealth Caritas.” (Certified Record (C.R.), OOR Exhibit 1, p. 000072)

2 [(]5) [c]laim [o]ffsets; [(]6) [v]oluntary [r]estitution; [(]7) [p]harmacy [a]udits; [and (]8) [c]ourt[-o]rdered [r]estitution[.] 8. All Independence Company documents pertaining to any request for [a] rate increase of 15% or more before raising premiums in [ ] Pennsylvania. 9. All Independence Company documents pertaining to the 80/20 [r]ule where insurance companies are required to spend at least 80% of the money they take in from premiums on health care costs and quality improvement activities[,] and the other 20% can go to administrative, overhead, and marketing costs. 10. All Independence Company documents pertaining to [m]edical [l]oss [r]atio. 11. All Independence Company documents pertaining to reviews or calculations of health insurance premiums, base prices[,] and rate adjustments for large groups (usually more than 50 employees) where insurance companies are required to spend at least 85% of premiums on care and quality improvement. 12. All Independence Company documents pertaining to reviews or calculations of health insurance premiums and rate adjustments by [the] Center[s] for Medicare [and Medicaid] Services [(CMS)] for location, age, tobacco use, plan category, and whether the plan covers dependents. 13. All Independence Company documents pertaining to differences in competition, state and local rules, and cost of living with regard[] to rate submissions as well as determinations of adequate competition for the Independence Companies within [ ] Pennsylvania. 14. All Independence Company documents pertaining to reviews or calculations of health insurance premiums for [p]lan category: [b]ronze, [s]ilver, [g]old, [p]latinum, and [c]atastrophic. 15. All documents pertaining to an [u]nreasonable [r]ate [i]ncrease where [the] Department reviews a rate increase that is subject to review and determines that[ (]1) the rate

3 increase is an unreasonable rate increase, [(]2) [] the increase is an excessive rate increase, [(]3) [] there is an unjustified rate increase, or [(]4) [there is] an unfairly discriminatory rate increase. 16. All documents pertaining to an [u]nreasonable [r]ate [i]ncrease where [the] Department determined that the rate increase is an excessive rate increase or that the increase causes the premium charged for the health insurance coverage to be unreasonably high in relation to the benefits provided under the coverage. 17. All documents where [the] Department determined that the rate increase results in a projected medical loss ratio below the [f]ederal standard in the applicable market to which the rate increase applies, after accounting for any adjustments allowable under [f]ederal law. 18. All documents where [the] Department determined that one or more of the assumptions on which a rate increase by an Independence Company is not supported or based on substantial evidence. 19. All documents where [the] Department determined that the choice of assumptions or combination of assumptions on which the rate increase is based [] is unreasonable. 20. All documents where [the] Department determined that the rate increase is an unjustified rate increase because an Independence Company provided data or documentation to [the] Department in connection with the increase that was incomplete, inadequate or otherwise did not provide a basis upon which the reasonableness of an increase may be determined. 21. All documents where [the] Department determined that the rate increase is an unfairly discriminatory rate increase if the increase results in premium differences between insureds within similar risk categories that[] (1) [a]re not permissible under applicable state law; or (2) [i]n the absence of an applicable state law, do not reasonably correspond to differences in expected costs.

4 22. All documents where [the] Department reviewed, determined or approved of[] ([1]) [t]he reasonableness of the assumptions used by the Independence Company health insurance issuer to develop the proposed rate increase and the validity of the historical data underlying the assumptions; ([2]) [T]he Independence Company health insurance issuer’s data related to past projections and actual experience; ([3]) [t]he Independence Company reasonableness of assumptions used to estimate the rate impact of the reinsurance and risk adjustment programs under [S]ections 1341 and 1343 of the Affordable Care Act[3][, 42 U.S.C.

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