Perez Ex Rel. Perez v. Blue Cross Blue Shield of Texas, Inc.

127 S.W.3d 826, 2003 WL 22964281
CourtCourt of Appeals of Texas
DecidedMarch 4, 2004
Docket03-03-00183-CV
StatusPublished
Cited by10 cases

This text of 127 S.W.3d 826 (Perez Ex Rel. Perez v. Blue Cross Blue Shield of Texas, Inc.) 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
Perez Ex Rel. Perez v. Blue Cross Blue Shield of Texas, Inc., 127 S.W.3d 826, 2003 WL 22964281 (Tex. Ct. App. 2004).

Opinion

OPINION

JAN P. PATTERSON, Justice.

In this insurance case, we must decide whether articles 21.21-6 and 21.21-8 of the insurance code allow a cause of action for denial of health insurance coverage to an individual with Down Syndrome. Appellant Brandon Perez, by and through his next friend, Debra Perez, individually and on behalf of similarly situated individuals, appeals the district court’s grant of sum *829 mary judgment in favor of appellee Blue Cross Blue Shield of Texas (“BCBSTX” or “Blue Cross”). Perez contends in five issues that the district court erred because (i) although he now has health insurance through another insurance company, his causes of action are not moot; (ii) he has valid claims under articles 21.21-6 and 21.21-8 of the insurance code; (iii) the denial of coverage was not based on the affirmative defense of “sound actuarial principles”; and (iv) the affidavit of Blue Cross’s actuarial expert should have been excluded. For the reasons set forth below, we affirm the order of the district court granting Blue Cross’s motion for summary judgment and denying Perez’s motions for summary judgment.

FACTUAL AND PROCEDURAL BACKGROUND

The pertinent facts of this case are not in dispute. In August 2000, Debra Perez applied for an individual Blue Cross health insurance policy for herself and her twelve-year-old son, Brandon Perez. She stated on the application that Brandon has Down Syndrome 1 but is “very, very healthy.” Blue Cross provided coverage for Debra but excluded Brandon from the policy because of his diagnosis of Down Syndrome. Debra requested reconsideration of the decision, asking why Blue Cross never requested copies of Brandon’s medical records or interviewed his doctor. She enclosed with her request a letter from Miguel Ibarra, M.D., Brandon’s doctor for ten years, who stated that Brandon did not require any more medical care than any other healthy boy his age. Blue Cross did not reconsider the application. In an internal e-mail some months later, a Blue Cross representative wrote that “[w]e did not request any medical information on Brandon because Down’s Syndrome is an automatic decline in our Underwriting Guidelines.”

Brandon, through his mother, filed suit in Travis County on behalf of himself and a putative class of all persons denied health insurance “based on a Down Syndrome diagnosis.” 2 Perez sought a declaratory judgment that Blue Cross’s practice of denying coverage to “healthy persons with Down Syndrome” violates, among other statutes, articles 21.21-6 and 21.21-8 of the insurance code and section 17.46(b)(12) of the deceptive trade practices act (DTPA). See Tex. Ins.Code Ann. arts. 21.21-6, 8 (West Supp.2004); Tex. Bus. & Com.Code Ann. § 17.46(b)(12) (West Supp.2004). 3 Perez farther sought to enjoin Blue Cross from denying health insurance coverage to “individuals diagnosed with Down Syndrome.”

Both Perez and Blue Cross filed traditional motions for summary judgment. Perez contended that he was entitled to summary judgment because Blue Cross did not raise the affirmative defense that its decision to deny coverage was based on “sound underwriting or actuarial principles *830 reasonably related to actual or anticipated loss experience.” Tex. Ins.Code Ann. art. 21.21-6, § 4(a). Blue Cross raised the affirmative defense in an amended answer and asserted that it was entitled to summary judgment because: Perez’s claims were moot because he obtained health insurance through another insurance company; Perez did not have valid causes of action under articles 21.21-6 and 21.21-8 of the insurance code; and the denial of health insurance coverage was justified because it was based on sound underwriting or actuarial principles reasonably related to actual or anticipated loss experience.

Perez then filed a no-evidence motion for summary judgment on the ground that Blue Cross presented no evidence of its affirmative defense, in part because Blue Cross’s actuarial expert, Jay Ripps, did not support his conclusions in his affidavit with actuarial data and based his conclusions on “additional materials provided to me by counsel.” The district court granted Blue Cross’s motion for summary judgment, denied Perez’s motions for summary judgment, and overruled Perez’s objection to the Ripps affidavit. Perez appeals the grant of summary judgment in favor of Blue Cross, the failure to exclude the Ripps affidavit, and the denial of his own motions for summary judgment.

ANALYSIS

Whether Perez’s Claims are Moot

In his first issue, Perez contends that the district court erred in granting summary judgment because his claims are not moot. Blue Cross argues that this case is moot because Perez has obtained health insurance through another insurer. We disagree with Blue Cross. Under the mootness doctrine, appellate courts may only determine cases in which an actual controversy exists. See Camarena v. Texas Employment Comm’n, 754 S.W.2d 149, 151 (Tex.1988); University Interscholastic League v. Buchanan, 848 S.W.2d 298, 304 (Tex.App.-Austin 1993, no writ). In general, a case becomes moot when the issues presented are no longer “live” or the parties lack a legally cognizable interest in the outcome. See United States Parole Comm’n v. Geraghty, 445 U.S. 388, 396, 100 S.Ct. 1202, 63 L.Ed.2d 479 (1980). Here, Perez retains a legally cognizable interest in the outcome were a court to issue an injunction that Blue Cross discontinue its practice of denying health insurance coverage to people with Down Syndrome. Furthermore, Perez has a live claim for actual damages. Because his causes of action are not moot, we sustain Perez’s first issue.

Admissibility of Blue Cross’s Actuarial Expert Witness Affidavit

In his fifth issue, Perez asserts that the district court erred by failing to exclude the affidavit of Jay Ripps, Blue Cross’s actuarial expert witness. Perez contends that Ripps’s reliance on “additional materials provided to me by counsel” is improper summary judgment proof because it cannot be readily controverted. See Tex.R. Civ. P. 166a(c).

The standard for the admissibility of expert testimony is the same on summary judgment as at trial. See United Blood Servs. v. Longoria, 938 S.W.2d 29, 30 (Tex.1997). In determining whether the testimony is admissible, the trial court does not determine whether the expert’s conclusions are correct, but only whether the analysis used to reach the conclusions is reliable. Gammill v. Jack Williams Chevrolet, 972 S.W.2d 713, 720 (Tex.1998). *831 As an appellate court, we do not consider the admissibility or inadmissibility of the evidence de novo.

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127 S.W.3d 826, 2003 WL 22964281, Counsel Stack Legal Research, https://law.counselstack.com/opinion/perez-ex-rel-perez-v-blue-cross-blue-shield-of-texas-inc-texapp-2004.