Prepaid Dental Services, Inc. v. Day

615 P.2d 1271, 1980 Utah LEXIS 997
CourtUtah Supreme Court
DecidedAugust 7, 1980
DocketNo. 16826
StatusPublished

This text of 615 P.2d 1271 (Prepaid Dental Services, Inc. v. Day) is published on Counsel Stack Legal Research, covering Utah Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Prepaid Dental Services, Inc. v. Day, 615 P.2d 1271, 1980 Utah LEXIS 997 (Utah 1980).

Opinion

WILKINS, Justice:

Plaintiff proposes to market a prepaid dental services plan which, it alleges, is not [1272]*1272an insurance plan and not subject to regulation under the Insurance Code. The Utah State Insurance Commissioner (Commissioner), however, determined both that the plan is within the definition of insurance in § 31-1-71 and is a Health Maintenance Organization (HMO), subject to regulation under § 31-42-1, et seq. The Commissioner also found that plaintiff did not propose to offer sufficient basic health services, required of HMOs under § 31-42-3(6) and denied plaintiff a Certificate of Authority, forbidding it to conduct business.

Plaintiff brought action in the District Court of Salt Lake County praying for declaratory judgment that the plan it proposed is not subject to regulation by the Insurance Commissioner. Both parties moved for summary judgment upon stipulated facts. The District Court granted defendant’s motion, sustained the findings of the Commissioner, and denied plaintiff’s petition. Plaintiff appeals.

Plaintiff’s plan consists of the following:

1. Plaintiff would contract with employers to arrange for specific dental services to be provided to the employer’s employees, as needed. The employers would pay to plaintiff a specific monthly charge, determined by the number of employees and their families who agreed to be participants.

2. Plaintiff would also contract with licensed dentists to provide these specific dental services. Plaintiff would pay the dentists a monthly payment whether they performed any services or not, the payments also being determined by the number of participants enrolled.

3. A participant would be required to have the dental services provided by the dentists with whom plaintiff had contracted, rather than choosing a dentist of his own, and for certain services would make scheduled co-payments to the dentists.

4. Plaintiff would require a performance bond from the dentists to ensure that the promised services continued to be available to participants during a contract year.

5. Plaintiff’s plan would not provide emergency care, in-patient hospital and physician care, out-of-area coverage or outpatient medical services.2

By § 31-1-7, the Utah Legislature has defined insurance:

Insurance is a contract whereby one undertakes to indemnify another or pay or allow a specified or ascertainable amount or benefit upon determinable risk contingencies.

Plaintiff asserts that its plan is not an insurance plan as the benefits it promises to participants do not involve determinable risk contingencies, and that plaintiff, by its various contracts, does not undertake to indemnify or assume any risk.

This Court has observed that insurance contracts involve “risk on the part of the insurer to pay on the happening of the contingency and the spreading of the risk over the group who pay the premiums.” (Justice Crockett’s concurring opinion in In re Clark’s Estate, 10 Utah 2d 427, 354 P.2d 112 (1960), quoted with approval in Utah Funeral Directors & Embalmers Assoc. v. Memorial Gardens, 17 Utah 2d 227, 408 P.2d 190 (1965).) To be sure, there is a certain risk, in this matter, that participants will need dental care, and that risk under plaintiff’s plan would be spread over the group of participants. Nevertheless, that risk is not assumed by plaintiff under its plan. Plaintiff would obligate itself to pay to the dentists no more (and no less) if the participants need dental care than if they do not need such care. It was just such a lack of assumption of any risk that led this Court to determine that the contracts in Clark, and Utah Funeral Directors, supra, were not insurance contracts.

[1273]*1273In Jordan v. Group Health Ass’n, 107 F.2d 239 (D.C.Cir.1939) the Court determined that a health plan, operated by a non-profit corporation which paid its enrolled doctors a monthly payment was not insurance, saying:

Whether the contract is one of insurance or of indemnity there must be a risk of loss to which one party may be subjected by contingent or future events and an assumption of it by legally binding arrangement by another. Even the most loosely stated conceptions of insurance and indemnity require these elements. Hazard is essential and equally so a shifting of its incidence. If there is no risk, or there being one it is not shifted to another or others, there can be neither insurance nor indemnity. Insurance also, by the better view, involves distribution of the risk, but distribution without assumption hardly can be held to be insurance. These are elemental conceptions and controlling ones, [at 107 F.2d 245]

Most courts which have considered this question have determined that such contracts do not constitute insurance where the professional is paid a “retainer” as distinguished from a fee for the service provided. See State ex rel. Fishback v. Universal Service Agency, 87 Wash. 413, 151 P.2d 768 (1915); Barmeier v. Oregon Physicians’ Service, 194 Or. 659, 243 P.2d 1053 (1952); California Physicians’ Service v. Garrison, 28 Cal.2d 790, 172 P.2d 4 (1946).

The District Court distinguished Fishback and Jordan on the ground that, here, plaintiff not only would agree to use its best efforts to obtain dental services for participants, but would require a performance bond of the dental group to assure the delivery of those services. The District Court held that the requirement of the performance bond indicated that plaintiff had assumed some risk. We do not agree. A performance bond might indicate that the indemnitor, or bondsman, had assumed a risk, but plaintiff, does not, under its plan, undertake to pay any benefit upon the happening of any contingency. Insurers are required under our code to maintain large deposits and reserves of assets in order to assure the public that the insurer will be able to meet its obligations to pay benefits upon the happening of a contingency, when it has assumed that risk. There is no reason to require such deposits and reserves of plaintiff as it would not obligate itself to pay anything in addition to the regular monthly payments to dentists pursuant to its contract with the dental group regardless of the happening of any contingency. Thus, plaintiff is not an insurer, as it would assume no risk.

Retainer plans, such as the one proposed by plaintiff have long been recognized as providing a beneficial and economical alternative to the dominant “fee for service” in delivery of health care. See note, Legal Problems of Group Health, 52 Harv.L.Rev. 809 (1939); Havighurst and Bovbjerg, Professional Standards Review Organizations and Health Maintenance Organizations: Are They Compatible?, 75 Utah L.Rev. 381 (1975).

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Related

California Physicians' Service v. Garrison
172 P.2d 4 (California Supreme Court, 1946)
Barmeier v. Oregon Physicians' Service
243 P.2d 1053 (Oregon Supreme Court, 1952)
Jordan v. Group Health Ass'n
107 F.2d 239 (D.C. Circuit, 1939)
In Re Clark's Estate
354 P.2d 112 (Utah Supreme Court, 1960)
State ex rel. Fishback v. Universal Service Agency
151 P. 768 (Washington Supreme Court, 1915)

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Bluebook (online)
615 P.2d 1271, 1980 Utah LEXIS 997, Counsel Stack Legal Research, https://law.counselstack.com/opinion/prepaid-dental-services-inc-v-day-utah-1980.