New Hampshire-Vermont Hospitalization Service v. Whaland

315 A.2d 191, 114 N.H. 92, 1974 N.H. LEXIS 216
CourtSupreme Court of New Hampshire
DecidedFebruary 15, 1974
DocketNo. 6723
StatusPublished
Cited by7 cases

This text of 315 A.2d 191 (New Hampshire-Vermont Hospitalization Service v. Whaland) is published on Counsel Stack Legal Research, covering Supreme Court of New Hampshire primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
New Hampshire-Vermont Hospitalization Service v. Whaland, 315 A.2d 191, 114 N.H. 92, 1974 N.H. LEXIS 216 (N.H. 1974).

Opinion

Kenison, C.J.

The primary issue in this case is the legality of the defendant insurance commissioner’s order of May 14, 1973, in reference to the operation of the Blue Cross plan in New Hampshire. The commissioner ordered an annualized rate increase of 4.7 percent, which was [93]*93substantially less than that sought by the plaintiff, and required the plaintiff by supplemental orders to:

1. Eliminate existing distinctions in coverage and rates between group and nongroup subscribers;
2. Increase the maximum major medical lifetime benefits from $30,000 to $250,000 per covered claimant and to provide a maximum coinsurance payable clause no greater than $1,000 per year per covered claimant “without an increase in the major medical rate level;”
3. Reconstitute its board of directors so that a majority represent the working men and women of the state.

On rehearing, this order was reaffirmed by the commissioner on August 14, 1973, and an appeal was filed by the plaintiff pursuant to RSA 419:13 (Supp. 1973) and RSA ch. 541, alleging various grounds wherein the order was unlawful or unreasonable. On September 11, 1973, this court granted the plaintiff’s motion for a temporary rate increase of 26.9 percent under bond, pending a determination of the legality of the May 14, 1973 order. New Hampshire-Vermont Hospitalization Service v. Whaland, 113 N.H. 461, 309 A.2d 508 (1973).

The factual context of the present case is similar to that of its companion case, New Hampshire-Vermont Physician Service v. Durkin, 113 N.H. 717, 313 A.2d 416 (1973), which involved the legality of the May 14, 1973 order in reference to the operation of the New Hampshire Blue Shield plan. Cf. In re New Hampshire-Vermont Hospitalization Service, 313 A.2d 6 (Vt. 1973). The history begins in July 1971, when Blue Cross filed for a rate increase of 33 percent in its basic subscriber contract and 14.8 per cent in the ’65’ contract pursuant to RSA 419:6. On May 8, 1972, after a series of joint hearings involving Blue Cross and Blue Shield, the insurance commissioner disapproved the request because the plaintiff had not met its burden of proof that the proposed rates were not “excessive, inadequate, or discriminatory.” The plaintiff proposed several modifications over the following months, and on July 27, 1972, the insurance commissioner fin[94]*94ally approved an annualized increase of 5.7 percent in Blue Cross’ total revenue for 1972. He also ordered both Blue Cross and Blue Shield to reduce their contingency reserve funds, which functioned to protect them from a condition of temporary insolvency resulting from unusually large claims arising from a catastrophe, epidemic or serious economic dislocation, to a level of one month’s claims and expenses.

The appropriate level of this fund has been disputed by the parties for several years. Although the fund had been considerably higher in former years, the plaintiff had been forced to lower its level so that by December 31, 1971 it amounted to 2.7 months of claims and expenses, approximately $8,000,000. At the hearings preceding the July 27, 1972 order, the insurance department’s actuaries testified that one month’s claims and expenses would be sufficient. Despite the testimony of the actuary of Blue Cross and Blue Shield that two months was the safe minimum, the plaintiff reluctantly agreed to try the level recommended by the department on a trial basis.

On November 30, 1972, Blue Cross filed for an average rate increase of 17.4 percent to become effective January 1, 1973. The contingency reserve fund had been reduced to approximately one month’s claims and expenses, and in the plaintiff’s view the proposed rate increase was designed to preserve the fund at this level. However, an insurance department actuary testified in joint hearings involving Blue Cross and Blue Shield that a ten-day reserve fund was adequate to meet the cash needs of the insurance companies. The insurance companies’ actuary testified that he still believed that a two-month reserve was the safe minimum. On May 14, 1973, the commissioner issued the present order which authorized a rate increase designed to lower the reserve fund to ten days of claims and operating expenses. He stated that a ten-day reserve, amounting to approximately $1,000,000, was sufficient to meet any unforeseen difficulties and stressed that the cash position rather than the balance sheet was the more accurate measure of Blue Cross’ ability to meet its obligations.

[95]*95Financial data was introduced on rehearing by the plaintiff which showed that as of December 31, 1972, the average contingency reserve of the seventy-four Blue Cross plans in this country was 1.78 months of claims and operating expenses and that for the nineteen plans in the same size category as the plaintiff (500,000 to 1,000,000 members), the average was 2.34 months. This data demonstrated that the plaintiff’s reserve of one month was lower than any other plan in its category (the nearest was 1.14 months), but. that eleven other plans in other categories had smaller reserves. It also revealed that if the ten-day requirement were put into effect, the New Hampshire plan would have a lower reserve than all but six plans in the country. The defendant insurance commissioner, however, was not persuaded by this evidence that the reasoning of his May 14, 1973 order was faulty and reaffirmed his previous ruling. On December 31, 1973, the plaintiff’s year-end statement showed that it lost $6,098, 055 in 1973, even after giving effect to the 26.9 percent rate increase, and that the balance sheet showed a deficit of at least $2,563,255.

The plaintiff’s primary contention is that the defendant’s order requiring the ten-day contingency reserve cannot be reasonably supported by the facts for the reasons set forth in New Hampshire-Vermont Physician Service v. Durkin, 113 N.H. 717, 313 A.2d 416 (1973). In that case we held that the record contained no evidence other than conclusory opinions to support the position that the ten-day reserve would be adequate for the New Hampshire Blue Shield plan. The plaintiff asserts that a ten-day reserve would place it in a precarious financial position because the amount of the reserve would be insufficient to protect it from the fluctuations of the economy or an unexpected catastrophe, and would force it to operate from time to time under a condition of temporary insolvency in which its assets would be less than its liabilities. To support this position, the plaintiff draws attention to the present deficit in its balance sheet.

The defendant argues, on the other hand, that, under RSA 541:13 the plaintiff must show by a clear prepon[96]*96derance of the evidence that the commissioner’s decision was unjust or unreasonable. He urges that the plaintiff has not met this burden of proof because, even though the 1973 year-end statement demonstrated that the defendant had miscalculated the appropriate rate increase to sustain a ten-day reserve, his order was reasonably designed to provide for the cash needs of the Blue Cross plan.

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Bluebook (online)
315 A.2d 191, 114 N.H. 92, 1974 N.H. LEXIS 216, Counsel Stack Legal Research, https://law.counselstack.com/opinion/new-hampshire-vermont-hospitalization-service-v-whaland-nh-1974.