Pennsylvania Dental Ass'n v. Commonwealth

398 A.2d 729, 41 Pa. Commw. 47, 1979 Pa. Commw. LEXIS 1324
CourtCommonwealth Court of Pennsylvania
DecidedMarch 5, 1979
DocketAppeal, No. 1579 C.D. 1977
StatusPublished
Cited by2 cases

This text of 398 A.2d 729 (Pennsylvania Dental Ass'n v. Commonwealth) 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
Pennsylvania Dental Ass'n v. Commonwealth, 398 A.2d 729, 41 Pa. Commw. 47, 1979 Pa. Commw. LEXIS 1324 (Pa. Ct. App. 1979).

Opinion

Opinion by

Judge MacPhail,

This is an appeal by the Pennsylvania Dental Association (PDA) and several individual dentists (Petitioners) from a decision of the Department of Insurance (Department) approving Amendment No. 5 to Filing No. 5-H-1970, a comprehensive prepaid dental program (Master Contract), which provides for dental insurance payments from Pennsylvania Blue Shield (Blue Shield) to its subscribers and participating dentists.

After the proposed amendment had been submitted to the Department in February of 1977 and after proper advertising, a public hearing was held on June 17, 1977. At the hearing testimony was presented by the Department, Blue Shield and PDA. On July 19, 1977, the Insurance Commissioner for the Commonwealth (Commissioner) approved the amendment.

Our scope of review is set forth in Section 44 of The Administrative Agency Law (Law), Act of June 4, 1945, P.L. 1388, as amended, 71 P.S. §1710.44.1

[50]*50All insurance contract provisions must be approved by tbe Department before they may be implemented.2 Prior to ruling upon any revisions, amendments or original contracts, the Department customarily affords interested persons the opportunity to be heard. Our case law indicates that

where, as here, a statute confers discretion upon an administrative tribunal, its actions are subject to judicial review only to determine whether or not there has been an abuse of discretion or a purely arbitrary exercise of authority. . . . Whether the court may have reached a different opinion or judgment in a particular case is not sufficient to reverse adminstrative action because judicial discretion may not be substituted for administrative discretion. (Citation omitted.)

Slanina v. Sheppard, 27 Pa. Commonwealth Ct. 376, 379, 366 A.2d 963, 965 (1976). PDA and Petitioners (collectively, Appellants) contend that the Department’s hearing in the instant case was conducted on an informal basis rather than a formal basis and that as a result “the atmosphere at the hearing prevented a record capable of supporting Department’s adjudication.” Appellants specifically complain that they were denied the right to cross-examine witnesses. We note from the record that the first witness called at the hearing was Mr. Archer, from the Department, who stated on behalf of the Commissioner that the hearing was permissive and that it was the Commissioner’s position that he could act upon the amendment without a hearing. Appellants made no objec[51]*51tion to that statement, and the hearing proceeded on an informal basis. Indeed, counsel for PDA acknowledged, during the course of the hearing, that he understood that it was an informal hearing and made no attempt to cross-examine any witnesses until near the end of the hearing when he was the one who did the cross-examining. Interestingly, he did so with the examiner’s permission. We dismiss this argument as being totally without merit.

Next, Appellants contend that the Department’s decision violates Section 34 of the Law, 71 P.S. §1710.-34,3 because its findings were insufficient to support the decision. While our holding in Begis v. Industrial Board of the Department of Labor and Industry, 9 Pa. Commonwealth Ct. 558, 308 A.2d 643 (1973), is applicable to this ease as contended by Appellants, we have no difficulty in distinguishing the facts in Begis from the facts now before us. In Begis we held that where there were no findings of fact, no conclusions of law and no reasons for the action taken, the agency’s decision was in clear violation of Section 34 of the Law. In the instant case the Commissioner’s decision was incorporated in a two and one-half page letter. While the letter contains no findings in numerical order and no references to specific testimony, it does summarize each of the substantive objections presented by PDA and states in very specific language why those objections were rejected. The necessary “finding” implied in the letter is that the Commissioner found no basis for any of PDA’s objections and therefore was compelled to approve the amendment. Again, we conclude that Appellants’ argument is without merit.

[52]*52Appellants’ main disagreement with the approval of the amendment is substantive. They argue that the amendment violates the present law in that: (1) it repeatedly conflicts with, and violates the purpose and intent of, 40 Pa. C.S. §101 et seq.; (2) it subverts the legislative intent by refusing to differentiate between “low-income” and “over-income” patients; and (3) it violates Section 129 of The Dental Law (Act), Act of May 1, 1933, P.L. 216, as amended, 63 P.S. §129, by purporting to authorize the unlicensed practice of dentistry. We will address these issues seriatim.

40 Pa. C.S. §6324(b) provides:

[A] professional health service corporation shall impose no restrictions on the health service doctors who administer to its subscribers, as to methods of diagnosis or treatment. The relation between a subscriber, or any of his dependents, and the health service doctor shall be identical with the relation that ordinarily exists in the community between a health service doctor and his patient. Subject to the provisions of subsection (a) of this section [relating to admission to plans], no person shall be permitted to interfere with the choice or selection by a patient of his health service doctor after that choice or selection has been made by an adult of sound mind.

Article III of the amendment provides that Blue Shield shall pay for certain services as set forth in the contract “provided they are deemed medically and dentally necessary by Blue Shield. ’ ’

Appellants contend that the amendment infringes on the dentist’s right to determine methods of diagnosis and treatment and that it somehow affects the dentists’ relationship with their patients so that that relationship cannot be that which “ordinarily exists [53]*53in the community.” Further, they contend that the proposed amendment will create doubt about a dentist’s competency and honesty. We cannot agree. The amendment does not even pretend to mandate what treatment a dentist may prescribe for or provide to his patients. The sole determination that Blue Shield makes is whether or not it will pay for the treatment rendered. The basis for that determination is whether the services to be rendered are medically and dentally necessary in the judgment of the insurer. The Commissioner correctly noted in his decision that “of course Blue Shield also has a continuing obligation to exert effective controls upon the cost of services to subscribers.” We conclude that the restriction imposed by the amendment fulfills Blue Shield’s obligation to its subscribers without infringing upon the professional obligations of any dentist to his patients.

Next, Appellants argue that Article TV" of the amendment also violates 40 Pa. C.S. §6324(b) because it authorizes Blue Shield to require the submission of a treatment plan including “substantiating material”, such as radiographs and study models, for a pre-determination of coverage by Blue Shield before services are rendered.

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Related

Pennsylvania Dental Ass'n v. Medical Service Ass'n
32 Pa. D. & C.3d 380 (Cumberland County Court of Common Pleas, 1982)
Apple v. Commonwealth, Department of Insurance
431 A.2d 1183 (Commonwealth Court of Pennsylvania, 1981)

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398 A.2d 729, 41 Pa. Commw. 47, 1979 Pa. Commw. LEXIS 1324, Counsel Stack Legal Research, https://law.counselstack.com/opinion/pennsylvania-dental-assn-v-commonwealth-pacommwct-1979.