Spectera, Inc. v. Wilson

749 S.E.2d 704, 294 Ga. 23, 2013 Ga. LEXIS 899
CourtSupreme Court of Georgia
DecidedNovember 4, 2013
DocketS12G1935
StatusPublished
Cited by5 cases

This text of 749 S.E.2d 704 (Spectera, Inc. v. Wilson) is published on Counsel Stack Legal Research, covering Supreme Court of Georgia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Spectera, Inc. v. Wilson, 749 S.E.2d 704, 294 Ga. 23, 2013 Ga. LEXIS 899 (Ga. 2013).

Opinion

BENHAM, Justice.

This appeal is from the grant of a petition for a writ of certiorari from a decision issued by the Court of Appeals in Spectera, Inc. v. Wilson, 317 Ga. App. 64 (730 SE2d 699) (2012). The record shows that appellant Spectera is a vision care insurer providing.eye care benefits coverage to Georgia residents. To provide eye care coverage for its insureds, Spectera contracts with different types of vision care providers including independent participating providers and retail chain providers. Appellee Steven M. Wilson is a licensed optometrist employedby StevenM. Wilson, O.D., PC., providing eye care services in Lowndes County as Wilson Eye Center (“WEC”). Appellees Cynthia McMurray, Jodie E. Summers, and David Price are also licensed optometrists employed by WEC. Prior to 2010, Spectera had entered provider contracts known as “Patriot contracts” with Wilson and McMurray, and they became members of Spectera’s panel of eye care providers. Summers likewise was on Spectera’s panel of eye care providers. Under the Patriot contract, independent participating providers such as appellees could use their own materials (lenses, frames, contacts) or materials obtained from any other source to service Spectera insureds who came to them for their eye care needs. Appellees’ business practice was to keep an inventory of materials that it obtained from third parties. Under the Patriot contract, Spectera would reimburse appellees for the materials Spectera insureds used from WEC’s inventory by paying appellees a fee for their materials’ costs and by having Spectera insureds remit a materials co-payment to appellees. See Spectera, Inc. v. Wilson, supra, 317 Ga. App. at 68.

In 2010, Spectera decided to terminate its Patriot contracts and replace them with independent participating provider (IPP) agreements. Spectera’s IPP agreement describes “Covered Vision Services” as follows:

The Provider shall provide a professional comprehensive eye examination, including tonometry, when indicated. The Provider shall provide professional and courteous dispensing and fitting of eyeglasses and/or contact lenses to Patients. When the use of a laboratory is required to provide services or products to Enrollees, the Provider agrees to use [Spectera’s [24]*24optical laboratory].1

(Emphasis supplied.) According to the affidavit of Lori Archer, Spectera’s Senior Vice President of Provider Network Solutions, this portion of the IPP agreement (the “covered materials requirement”) means independent participating providers like appellees would be required to obtain covered materials (lenses, frames, and “formulary contact lenses”) from Spectera when servicing Spectera insureds. Under this agreement, Archer states the only materials independent participating providers like appellees may provide to Spectera insureds, regardless of the source of the materials, would be non-covered materials such as prescription sunglasses or spare pairs of eyeglasses. In addition, Spectera admitted in its court filings that under the IPP agreement “[appellees] would no longer receive the reimbursement for materials from Spectera and would no longer be entitled to retain the materials co[-]pays from Spectera insureds.” Spectera maintains the IPP agreement is more cost-effective for its insureds who seek eye care from independent eye care providers. In contrast to its IPP agreements with independent participating providers, Spectera does not impose a covered materials requirement in its contracts with the retail chain providers (i.e., Walmart). Thus, retail chain providers which service Spectera insureds may source their materials from any laboratory of their choosing and prepare those materials directly for Spectera insureds.

Appellees sued Spectera contending that Spectera’s proposed IPP agreement violated various subsections of Georgia’s Patient Access to Eye Care Act, OCGA § 33-24-59.12 (the “Act”). While the case was pending, the trial court issued a temporary injunction prohibiting Spectera from forcing its panel of independent participating providers in Georgia to abide by the IPP agreement. After the trial court temporarily enjoined Spectera from enforcing its IPP agreement, Spectera sought to remove appellees Wilson, Summers, and McMurray from its approved panel of providers altogether; but the trial court enjoined Spectera from taking such action. Although appellee Price was not on Spectera’s provider panel, he alleged Spectera violated the Act by denying him membership on its panel because of his refusal to sign the IPP agreement. Upon considering the parties’ cross-motions for summary judgment, the trial court [25]*25granted appellees’ motions for summary judgment, denied Spectera’s motion for summary judgment and issued a permanent injunction precluding Spectera from enforcing the restrictions contained in the IPP agreement as to “any other licensed eye care provider on [Spectera’s] provider panel” or those who had applied for admittance to the panel. The trial court later modified its injunction by suspending it “as to eye care providers other than [appellees] pending a final determination on appeal.”

Spectera appealed the trial court’s decision to the Court of Appeals which affirmed in part and reversed in part. The Court of Appeals found that the covered materials requirement in the IPP agreement violated subsections (c) (2)2 and (c) (5)3 of the Act in regard to independent optometrists, and so it affirmed appellees’ motions for summary judgment in regard to those subsections of the Act. Spectera, Inc. v. Wilson, supra, 317 Ga. App. at 69, 73. The Court of Appeals found no violation of subsection (c) (3),4 and so it reversed the trial court’s grant of summary judgment to the appellees in regard to that subsection. Id. at 73. As to subsection (c) (6)5 of the Act, the Court of Appeals determined Spectera violated that subsection because it “unlawfully utilized an improper condition to exclude [appellee Price] from his initial admittance to the Panel,” (id. at 74), and so it affirmed the grant of summary judgment to Price. Finally, the Court of Appeals limited the award of injunctive relief to independent optometrists. We granted Spectera’s petition for a writ of certiorari and requested that the parties respond to the following question: “Did the Court of Appeals correctly construe OCGA § 33-24-59.12 (c) of the [26]*26Patient Access to Eye Care Act?” For the reasons below, we affirm in part, reverse in part, and vacate in part.

1. Spectera contends the Court of Appeals erred when it construed subsections (c) (2), (c) (3), and (c) (5) of the Act. We discuss Spectera’s allegations regarding these subsections in turn.

(a) Spectera contends that its IPP agreement does not violate subsection (c) (2) of the Act. That subsection provides that an insurer “shall . . . [n]ot preclude a covered person who seeks eye care from obtaining such service directly from a provider on the health benefit provider panel who is licensed to provide eye care.” Spectera argues the Court of Appeals erred when it found that the IPP agreement’s covered materials requirement effectively required Spectera insureds to purchase their materials directly from Spectera. See Spectera, Inc. v. Wilson, supra, 317 Ga. App.

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Bluebook (online)
749 S.E.2d 704, 294 Ga. 23, 2013 Ga. LEXIS 899, Counsel Stack Legal Research, https://law.counselstack.com/opinion/spectera-inc-v-wilson-ga-2013.