Rose v. Board of Review in the Division of Insurance

195 N.E.2d 82, 346 Mass. 581, 1964 Mass. LEXIS 835
Massachusetts Supreme Judicial Court·Decided January 3, 1964·Published·Cited by 3 cases

Opinion

Kirk, J.

The principal parties in interest to this litigation are two: the defendant Massachusetts Medical Service, Inc. (Blue Shield), a medical service corporation organized pursuant to the provisions of G. L. c. 176B, § 2, and the plaintiff, a participating physician, as defined in G. L. c. 176B, § 1, under contract with Blue Shield. The de[582] fendant Board of Review in the Division of Insurance (the board) became a party when the plaintiff, who had submitted his dispute with Blue Shield to the board under G-. L. c. 176B, § 12, was aggrieved by its decision and sought a review in the Superior Court. The judge upheld the board whose decision was unanimous. It is agreed that we have before us all the evidence, almost entirely documentary, which is necessary for the determination of the case.

The immediate question for decision is whether, in the circumstances to be stated, the plaintiff, as ordered by the board, must return the sum of $109 paid to him by a patient whom he had attended in January and February, 1961. The plaintiff’s bill for services was $300. Blue Shield paid him $191; the patient paid him the balance of $109. The patient was an employee of Harvard University (Harvard). Unknown to the plaintiff, Harvard had made an agreement with Blue Shield whereby Harvard agreed to pay monthly to Blue Shield 108% of the amounts paid by Blue Shield to participating physicians for services rendered to Harvard’s covered employees.1 The agreement was filed with the Division of Insurance of the Commonwealth on July 20, 1960, and was effective July 1, 1960. Annexed to the agreement and incorporated by reference in it was a “subscriber’s certificate” which set out in meticulous detail the benefits, subject to certain definitions, limitations and exclusions, which are available from Blue Cross and Blue Shield to a “member” covered by the “contract.” The “contract” is defined as “this Certificate, Riders, if any, the application card, and any Supplemental Agreements.” A “member” means “each person eligible for benefits under a membership. ” “ Subscriber’ ’ means ‘ the [583] individual with whom Blue Cross-Blue Shield has entered into a contract.”

It is undisputed that the patient was, under the definition in the subscriber’s certificate, a “service benefit member,” who, as such, was not required to make payments to participating physicians above the payments made by Blue Shield as provided in its schedule of fees.

Underlying the plaintiff’s assertion that he is not required to remit $109 to the patient is the contention that the agreement between Blue Shield and Harvard is invalid because it does not comply with the provisions of G. L. c. 176B, § 4, as amended by St. 1960, c. 307, § 1, with the result, it is argued, that the plaintiff is not a participating physician as to the employees of Harvard. One of the gronnds of invalidity asserted by the plaintiff is that, under the arrangement described, Harvard is a “subscriber” to Blue Shield but, under the statute, is in fact ineligible to be a “subscriber.” It is, of course, quite clear that by definition in G. L. c. 176B, § l,2 and in the context of the statute as a whole,3 Harvard is not eligible to be a subscriber since the term contemplates a human being to whom and to whose eligible dependents the medical services or benefits are to be available. The definition of the word “subscriber” in the subscriber’s certificate, above referred to, likewise repels the suggestion that Harvard is a “ subscriber ’ ’ to Blue Shield. The fact that Harvard cannot be a “subscriber” does not, however, in any way affect its capacity to make the described agreement with Blue Shield.

Agreements of the type entered into by Blue Shield and Harvard are recognized and expressly authorized by St. 1960, c. 307, § 1, enacted as an emergency measure, [584] which substituted a new § 4 for that which had theretofore existed. The 1960 statute deals with and regulates two types of agreement by a medical service corporation, “a non-group medical service agreement” and “a group medical service agreement.” We are concerned primarily with the latter type which the statute defines as: “Any agreement between a medical service corporation and a group of five or more persons or with the employer, employers or other representatives of such group whereby the medical service corporation undertakes to furnish benefits for medical service to said persons and to their covered dependents, if any . . .. ” The statute goes on to provide: ‘ ‘ Under such a group medical service agreement, subscription certificates and the rates charged by the corporation [Blue Shield] to the subscribers shall be filed with the commissioner within thirty days after their effective date, and shall be subject to subsequent disapproval by the commissioner if he finds that the benefits provided therein are unreasonable in relation to the rate charged, or that the rates charged are excessive, inadequate or unfairly discriminatory.”

The 1960 statute, in paragraph two of § 1, which deals with a nongroup agreement (an “agreement between a medical service corporation and a person”), requires that “the form of subscription certificate and the rates charged by such corporation to the subscribers shall be filed with and receive the prior approval of the commissioner. ” Section 2 of the same statute, in amendment of G. L. c. 176B, § 6,4 requires that a subscription certificate be issued to each nongroup subscriber.

We think that these differences, relating to the regulation of group and nongroup agreements, in the 1960 statute, are significant in the determination of the question raised by the plaintiff.

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Rose v. Board of Review in the Division of Insurance, 195 N.E.2d 82, 346 Mass. 581, 1964 Mass. LEXIS 835 (Mass. 1964).

195 N.E.2d 82 (Rose v. Board of Review in the Division of Insurance) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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