National Plan Administrators, Inc. v. National Health Insurance Co.

150 S.W.3d 718, 2004 WL 2027923
CourtCourt of Appeals of Texas
DecidedNovember 18, 2004
Docket03-03-00306-CV
StatusPublished
Cited by23 cases

This text of 150 S.W.3d 718 (National Plan Administrators, Inc. v. National Health Insurance Co.) is published on Counsel Stack Legal Research, covering Court of Appeals of Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
National Plan Administrators, Inc. v. National Health Insurance Co., 150 S.W.3d 718, 2004 WL 2027923 (Tex. Ct. App. 2004).

Opinion

OPINION

W. KENNETH LAW, Chief Justice.

In this case, we must consider the nature of the relationships among an underwriter, a marketing agency, and a third-party administrator in the insurance industry. The trial court determined that the third-party administrator owed the underwriter a fiduciary duty, and a jury assessed damages. In addition, the jury determined that the marketing agent and the third-party administrator operated as a single-business enterprise and so the court assessed all damages, including exemplary damages based on a finding of malice, jointly and severally against the administrator and the marketing agent. For the reasons stated below, we affirm the judgment of the trial court.

BACKGROUND

Appellee National Health Insurance Company (“National Health”) is a health and accident insurance underwriter, issuing individual policies primarily to self-insured individuals, small groups, and families. It contracted with agents, called “captured agents,” who are obligated by contract to sell only National Health policies. Appellant CRS Marketing Agency (“CRS”) is an insurance agency that focuses on marketing supplemental insurance products purchased through payroll deductions from public sector employees and is owned entirely by Clyde Sommerlatte. It earns commissions on policies sold, which generally include a large commission for the first year or two of the policy with decreasing commissions on subsequent renewals.

In the 1970s, insurance companies began contracting with other business entities, called “third-party administrators,” to perform administrative functions for their insurance policies, such as managing sales of policies, providing administration services for policyholders, servicing claims, providing accounting and other administrative functions for group and individual insurance policies, collecting premiums, and collecting and storing information about insured parties. This arrangement allowed insurance underwriters to focus on risk allocation while outsourcing their marketing and administrative functions. In 1987, Texas began to regulate third-party administrators, and the legislature passed the current regulatory statute in 1989. See Tex. Ins.Code Ann. art. 21.07-6 (West Supp.2004); see also Act of July 20, 1987, 70th Leg., 2nd C.S., ch. 76, § 1, 1987, Tex. Gen. Laws 238, 238-^9. Third-party administrators charge fees for their services as the source of their profits. Appellant National Plan Administrators is a third-party administrator and is owned entirely by CRS. National Plan Administrators provides its services to CRS and to other insurance carriers as well.

Another major change in the insurance industry occurred in the mid-1980s when Congress authorized employers to establish “cafeteria plans.” See 26 U.S.C.A. § 125 (West Supp.2004). Under a cafeteria plan, an employee may request an employer to reduce an employee’s wages by a certain amount in exchange for the employer purchasing insurance on behalf of *725 the employee or for reimbursing the employee for medical or child-care expenses. See id. § 125(d). These deductions are made before taxes are deducted from the employee’s pay. See id. § 125(a). The employer also receives a benefit by being allowed to deduct these expenditures from its federal taxes as business expenses. See id. § 3121(a)(5)(G). Selling an insurance product through a cafeteria plan requires the employer who sponsors the plan to agree to include a particular insurance product in the plan. During the 1980s and 1990s, CRS developed a series of supplemental health insurance products, described as “Cancer and Dread Disease Policies,” that were underwritten by American Heritage Life Insurance Company (“American Heritage”). It sold some of these policies to individual employees through cafeteria plans.

Before 1995, CRS decided to move some of its “book of business” 1 from American Heritage to another carrier. Thus, Som-merlatte entered into negotiations with National Health concerning CRS insurance products. According to his proposal, National Health would provide underwriting of the policies while National Plan Administrators would perform all administrative functions pertaining to licensing, commissions, policy underwriting, claims, customer service, and other functions. National Plan Administrators would also conduct the marketing of the products, using its pre-existing relationships with employers to introduce these new products. Thus, it would act as an extension of National Health, performing many of the duties and responsibilities that National Health, as an insurer, would normally retain for itself. 2 Within its role, it would also hold proprietary information that belonged to National Health.

According to G. Scott Smith, former president of National Health, discussions concerning this relationship focused on creating a “request for proposal” process for generating business. In a request for proposal, a marketing entity, such as CRS, would approach an employer and obtain approval to add the company’s name to the list of authorized providers under the cafeteria plan. Then, during the enrollment period for the plan, it would submit a proposal and take applications from individual employees who decided to apply for the insurance product.

National Plan Administrators submitted a proposed contract to National Health in April 1995, and National Plan Administrators and National Health signed two documents that year — an “Administrative, Compensation and Claim Service Agreement” and a “Sharing Agreement.” 3 In those documents, National Plan Administrators created a profit-sharing arrangement with National Health. National Health would underwrite catastrophic illness (Cancer and Dread Disease policies) and National Plan Administrators would administer the policies and service the *726 claims according to policy standards and procedures provided by National Health. National Plan Administrators would also “solicit eligible persons for enrollment or application for coverage, ... draft, print, and distribute descriptive brochures and other promotional materials.” Policies would be marketed exclusively through National Plan Administrators. In addenda, National Plan Administrators identified CRS as its agent for marketing the National Health policies. Both National Health and National Plan Administrators recognized that National Plan Administrators would work as an independent contractor under the agreements and would continue to provide services to other parties. It also provided for unilateral termination of the agreement by National Health for a variety of reasons. According to the Sharing Agreement, National Health would retain all profits up to five percent of the gross premiums collected for cancer policies, and any profit above that amount would be 'shared equally between National Health and National Plan Administrators. National Plan Administrators would determine profits, which would only be calculated after it had collected over two million dollars in annualized premiums. As an addendum, Som-merlatte personally promised to indemnify National Health from any liability it might incur from American Heritage as a result of the sale of cancer policies.

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Bluebook (online)
150 S.W.3d 718, 2004 WL 2027923, Counsel Stack Legal Research, https://law.counselstack.com/opinion/national-plan-administrators-inc-v-national-health-insurance-co-texapp-2004.