Obstetricians-Gynecologists, P.C. v. Blue Cross & Blue Shield

361 N.W.2d 550, 219 Neb. 199, 1985 Neb. LEXIS 906
CourtNebraska Supreme Court
DecidedFebruary 8, 1985
Docket83-646
StatusPublished
Cited by44 cases

This text of 361 N.W.2d 550 (Obstetricians-Gynecologists, P.C. v. Blue Cross & Blue Shield) is published on Counsel Stack Legal Research, covering Nebraska Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Obstetricians-Gynecologists, P.C. v. Blue Cross & Blue Shield, 361 N.W.2d 550, 219 Neb. 199, 1985 Neb. LEXIS 906 (Neb. 1985).

Opinion

Grant, J.

This is an appeal by the plaintiff, Obstetricians-Gynecologists, P.C., a Nebraska professional corporation (hereinafter OB-GYN), from the district court’s denial of OB-GYN’s petition for a declaratory judgment and the court’s denial of certification of the “class” of physicians which OB-GYN sought to represent in this action.

The action was brought by OB-GYN under the Uniform Declaratory Judgments Act, Neb. Rev. Stat. §§ 25-21,149 et seq. (Reissue 1979), seeking to determine the validity of a nonassignment provision in health care contracts issued by *200 defendant-appellee, Blue Cross and Blue Shield of Nebraska, a nonprofit hospital service corporation (hereinafter Blue Shield).

After trial the court denied the relief sought by OB-GYN. OB-GYN appeals, alleging three assignments of error. The first two assignments may be combined in that they allege generally that the trial court erred in not holding Blue Shield’s nonassignment provisions void as a matter of public policy. The third assignment of error alleged by OB-GYN is that the trial court erred “in finding that the plaintiff did not meet the requirements of a class action.” For the reasons hereinafter set out we affirm the action of the trial court.

OB-GYN is a corporation of physicians providing health care services to patients. Blue Shield is in the business of writing health care insurance, including insurance for prepaid medical, surgical, hospital, nursing home, dental, and similar services. Its existence is authorized under the hospital service corporations statutes, Neb. Rev. Stat. §§ 21-1509 et seq. (Reissue 1983).

Blue Shield provides health care insurance to its members, who are known as “subscribers,” and to certain members of subscribers’ families if agreed upon. Subscribers are individuals — most of them belonging to groups such as employee groups, labor unions, or governmental or professional associations. These individuals, either alone or through their groups, enter into contracts with Blue Shield whereby, upon payment of a periodic subscription premium by the subscriber or on his behalf, Blue Shield agrees to pay a certain amount for described health care services contracted for by the subscriber. The amount to be paid is determined by the terms of the insurance contract between Blue Shield and the subscriber.

The hospitals, physicians, and others who provide health care services to the subscribers are known as “providers.” Following its “Physician’s Voluntary Cost Effectiveness” program, instituted in 1978, Blue Shield entered into separate contracts with providers who wish to participate in Blue Shield’s program. The providers who enter into these contracts with Blue Shield are called “participating” providers. Each of *201 the contracts between Blue Shield and the participating providers requires the providers to accept agreed-upon payments for specified services as payment in full, and requires Blue Shield to pay each participating provider directly.

Providers who have not entered into contracts with Blue Shield to accept agreed-upon payments as payment in full are called “nonparticipating” providers. OB-GYN is a nonparticipating provider.

The amount of benefits paid by Blue Shield does not depend on whether services are provided by a participating or nonparticipating provider. The payment is the same in either case. However, where services are rendered by a participating provider, payment is made directly to the provider by Blue Shield on behalf of the subscriber — as provided in the Blue Shield-subscriber insurance contract. When the services are performed by a nonparticipating provider, on the other hand, payment is made by Blue Shield directly to the subscriber — also as provided in the Blue Shield-subscriber insurance contract. These payment provisions are included in all Blue Shield-subscriber contracts.

It is provided in the Blue Shield-subscriber insurance contract that benefits payable to a subscriber may not be assigned by the subscriber. The nonassignment provision in the Blue Shield-subscriber contract states: “No assignments of any amounts payable under this Contract shall be recognized or accepted by, or binding upon, the Company.” Blue Shield’s president testified as to the reason that Blue Shield inserted the nonassignment provisions in its contracts with its subscribers. That reason was stated to be that Blue Shield wished to have nonparticipating providers join the Blue Shield program so that they would accept the Blue Shield payment under the policy as payment in full for the medical services rendered, and thus help to keep down the costs of medical services to the subscribers. The only inducement that Blue Shield could offer to any provider was payment directly to the provider.

Prompt payment by Blue Shield directly to participating providers lessens the financial burden of debt collection for those providers, and ensures payment to the participating providers for health care services rendered. In an effort to *202 collect payment directly from Blue Shield for services it provides to Blue Shield subscribers, OB-GYN (although it is a nonparticipating provider) has taken ássignments of Blue Shield subscribers’ benefits and submitted them to Blue Shield for payment. Blue Shield, relying on the nonassignment clause in its contracts with its subscribers, refuses to pay OB-GYN directly, but instead sends the payment to the subscriber. It is OB-GYN’s attack on the validity of this nonassignment clause that forms the basis for this suit.

With regard to the three assignments of error as a whole, we first note that a declaratory judgment action is sui generis and may involve questions of both law and equity. S.I.D. No. 32 v. Continental Western Corp., 215 Neb. 843, 343 N.W.2d 314 (1983). Insofar as fact questions are concerned in a declaratory judgment action, those issues may be tried and determined as in other civil actions. § 25-21,157. All declaratory judgment decrees may be reviewed as other decrees. § 25-21,155. Pursuant to Neb. Rev. Stat. § 25-1925 (Reissue 1979), insofar as the appeal is one in equity, we review the trial court’s finding of fact de novo on the record. With regard to questions of law, we have the obligation to reach independent conclusions with respect to those questions. Ranger Division v. Bayne, 214 Neb. 251, 333 N.W.2d 891 (1983); In re Estate of Corrigan, 218 Neb. 723, 358 N.W.2d 501 (1984). Also, in our review of this case on the questions of public policy, while our review is de novo, we note that in Beaver Lake Assn. v. Beaver Lake Corp., 200 Neb. 685, 691, 264 N.W.2d 871

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361 N.W.2d 550, 219 Neb. 199, 1985 Neb. LEXIS 906, Counsel Stack Legal Research, https://law.counselstack.com/opinion/obstetricians-gynecologists-pc-v-blue-cross-blue-shield-neb-1985.