State Farm Mutual Automobile Insurance v. Mortell

667 N.E.2d 192, 1996 Ind. App. LEXIS 811, 1996 WL 334223
CourtIndiana Court of Appeals
DecidedJune 19, 1996
DocketNo. 49A04-9501-CV-3
StatusPublished
Cited by3 cases

This text of 667 N.E.2d 192 (State Farm Mutual Automobile Insurance v. Mortell) is published on Counsel Stack Legal Research, covering Indiana Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
State Farm Mutual Automobile Insurance v. Mortell, 667 N.E.2d 192, 1996 Ind. App. LEXIS 811, 1996 WL 334223 (Ind. Ct. App. 1996).

Opinion

OPINION

RILEY, Judge.

STATEMENT OF THE CASE

Plaintiffs-Appellants State Farm Mutual Automobüe Insurance Company and State Farm Fire & Casualty Company (“State Farm”) appeal from the judgment of the trial court which affirmed the Final Order issued [194]*194by Appellees-Defendants the Indiana Department of Insurance (“IDI”). The Final Order was the result of a market conduct examination of State Farm which compared State Farm’s handling of claims for treatment by chiropractic physicians with its handling of claims for treatment by other medical providers. Appellee, the Indiana State Chiropractic Association (“ISCA”) was an in-tervenor below. The Insurance Institute of Indiana filed a brief as amicus curiae asking this court to reverse the trial court’s decision and to find in favor of State Farm.

We affirm.

ISSUES

The following restated and consolidated issues are presented for our review:

1. Whether IDI acted properly when it conducted an investigatory hearing to review the findings of the market conduct examination and ordered State Farm to take specific actions, and whether this procedure deprived State Farm of its due process rights.
2. Whether IDI properly applied the Indiana statute governing the reimbursement for medical services to State Farm’s automobile and homeowner insurance policies and whether IDI properly applied the term “equal basis” within the meaning of the statute.
3. Whether IDI’s Final Order is supported by substantial evidence.

FACTS AND PROCEDURAL HISTORY

The conflict at issue began in 1991, when Edward Treacy, the Executive Director of ISCA wrote a letter to then IDI Commissioner, John Dillon, lodging a formal complaint against State Farm and requesting that IDI perform a market conduct examination of State Farm, with specific emphasis on the company’s use of outside claims review organizations. Specifically, ISCA alleged that State Farm was discriminating against chiropractors in the payment of claims. After receiving this letter, IDI decided to perform a target market conduct examination and retained the independent firm of Milli-man & Robertson to conduct the examination. Milliman & Robertson is a group of actuaries and health care consultants in the business of providing a wide variety of services including actuarial services to life, health, pension and casualty insurance organizations.

A market conduct examination is a statutorily provided tool by which the insurance commissioner can review a particular aspect of the interaction between an insurance carrier and the general public. A target examination is limited to a specific issue which the market behavior of the company has precipitated, and is usually conducted on an immediate basis and sometimes with no notice to the company.

In this case, IDI provided State Farm with notice of its intent to conduct the examination. After several obstacles were overcome1, the examination began on June 17, 1991, approximately 20 days after State Farm received notice of IDI’s intent to conduct the examination. The examination took place over a one week period and was conducted at the regional offices of State Farm in Lafayette, Indiana. The examiners used a random selective sample of files of State Farm’s choice to review the company’s practices with regard to the reimbursement of chiropractic claims. The team of examiners from Milliman & Robertson generated a report of its findings and forwarded it to IDI, along with a Recommended Order.

Upon receipt of the report, IDI sent a copy to State Farm and advised State Farm that it had 15 days in which to file any objections. State Farm responded in writing that it objected to the wording suggesting that State Farm’s Medical Cost Management program was not in compliance with Indiana insurance law.

[195]*195Milliman & Robertson reached the following conclusions based on its examination of State Farm’s claims payment practices:

— State Farm uses outside review organizations to review chiropractic claims much more frequently than for other practitioners performing like services.
— For auto and fire claims involving medical services, State Farm has no uniform practices or policy stating when medical claims should be reviewed externally.
— We found no pattern indicating when State Farm claims examiners would use outside review agencies for chiropractic claims (such as Professional Evaluation Services, Inc. (PES)).
— Claims analysts use their own judgment (often in consultation with their supervisor or the claims superintendent) as to when they use outside review organizations for further medical claims review.
— State Farm needs to establish documented utilization review criteria to decide when claims need further review, both for chiropractic as well as medical services, for the auto and fire claims processing.
— We found no evidence of any written criteria or “red flag” policy which required State Farm claim examiners to use outside review.

(R. 10-11).

After reviewing the market conduct examination, John F. Mortell, the newly appointed Commissioner of IDI, issued the Department’s findings of fact, conclusions of law and order regarding State Farm’s claims practices. The Commissioner formally adopted the market conduct examination report prepared by Milliman & Robertson and found in relevant part that State Farm treats claims involving chiropractic services differently than claims involving other health care providers, and that State Farm does not reimburse chiropractors for their services on an equal basis with other health care providers who perform the same service. IDI further ordered State Farm to establish written guidelines for its handling of chiropractic claims and for the organization and maintenance of automobile and fire claims files. One month after its issuance, IDI rescinded this order for the purpose of granting State Farm an opportunity for a formal hearing.

IDI then promptly notified State Farm that a hearing pursuant to Ind.Code 4-21.5-1-1 et seq. was scheduled for December 17, 1991, with Commissioner Mortell presiding. State Farm filed a motion seeking Commissioner Mortell’s recusal as Administrative Law Judge (ALJ) due to his alleged biased position, a request for a more definite statement of the charges and a request for a pre-hearing conference. A pre-hearing conference was held with Commissioner Mortell sitting as ALJ, wherein he denied all of State Farm’s requests, including the request to disqualify himself. Following the pre-hear-ing conference, State Farm brought an action in the Marion Circuit Court seeking judicial review of Commissioner Mortell’s denial of State Farm’s petition to disqualify. That same day, prior to the issuance of any judicial ruling, Commissioner Mortell withdrew as ALJ and appointed Lawrence Reuben to preside as ALJ over all proceedings including “the hearing, which proceedings and hearing shall be held in accordance with Ind. Code § 27-1-3.1-1 et seq.” (R. 183).

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667 N.E.2d 192, 1996 Ind. App. LEXIS 811, 1996 WL 334223, Counsel Stack Legal Research, https://law.counselstack.com/opinion/state-farm-mutual-automobile-insurance-v-mortell-indctapp-1996.