State Medical Society v. Oxford Hlth. P., No. X01cv0165664s (Dec. 13, 2001) Ct Page 16582

2001 Conn. Super. Ct. 16581
CourtConnecticut Superior Court
DecidedDecember 13, 2001
DocketNo. X01 CV 0165664S
StatusUnpublished

This text of 2001 Conn. Super. Ct. 16581 (State Medical Society v. Oxford Hlth. P., No. X01cv0165664s (Dec. 13, 2001) Ct Page 16582) is published on Counsel Stack Legal Research, covering Connecticut Superior Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
State Medical Society v. Oxford Hlth. P., No. X01cv0165664s (Dec. 13, 2001) Ct Page 16582, 2001 Conn. Super. Ct. 16581 (Colo. Ct. App. 2001).

Opinion

[EDITOR'S NOTE: This case is unpublished as indicated by the issuing court.]

MEMORANDUM OF DECISION ON DEFENDANT'S MOTION TO DISMISS OR STAY PROCEEDINGS
The defendant, Oxford Health Plans (CT), Inc. ("Oxford") has moved to dismiss, or, alternatively, to stay the above-captioned action on two grounds: (1) that the plaintiff lacks standing to assert the claims therein on its own behalf, and (2) that the plaintiff may not pursue on behalf of its members claims that the members have a contractual duty to arbitrate.

The court conducted a hearing, and the parties have filed both pre- and post-hearing briefs concerning the issues raised in the motion.1

The court finds that the Society lacks standing to assert the claims of its members because all of those claims are issues that the members are required by the provisions of written contracts to arbitrate with the plaintiff. The court finds that the Society has sufficiently alleged a direct injury to itself to have standing to pursue that injury.

Claims made

In its amended complaint, the plaintiff, Connecticut State Medical Society ("Society") alleges that it is "a federation of eight county medical associations and a constituent entity of the American Medical Association" with membership of over 7,000 physicians. The Society alleges that its "philosophy and purpose . . . is to promote the highest standards of medical care in the State of Connecticut, to work to preserve the integrity and independence of physicians, and to support the sanctity of the physician-patient relationship for the benefit of the public by, among other things, facilitating and assisting its physician members in providing top quality care to patients, providing them with a unified voice and enabling them to take concerted action on behalf of their profession and of their patients, and acting and advocating on their behalf to preserve the ability, independence and freedom of physicians to render the best possible care to every patient." (Amended complaint, para. 2.) CT Page 16583

The Society alleges that it has been injured and that its members have also been injured by certain practices and actions of Oxford.2 It seeks injunctive relief against practices "which are designed to delay, deny, impede and reduce lawful reimbursement to [Society member] physicians who are participating physicians in defendant's network and who have rendered medically necessary health care service to members of defendant's managed care plans." (Amended complaint, para. 5.)

The Society alleges that it does not bring the action as an assignee of enrollees' right to benefits. (Amended complaint, para. 5.)

The foregoing summary is the Society's own characterization of the claim that is set forth in the paragraphs of its amended complaint that begin at paragraph 12 of the amended complaint. In those factual allegations, the Society alleges that Oxford insures Connecticut residents who select health care providers from a network of participating physicians who enter into written agreements with Oxford. These agreements contain terms governing the fees that physicians will be paid for treating Oxford enrollees.

The sole cause of action alleged by the Society is that the acts and practices alleged constitute unfair and deceptive trade practices in violation of the Connecticut Unfair Trade Practices Act, ("CUTPA"), Conn. Gen. Stat. § 42-110a et seq.

The Society limits the remedies it seeks to injunctive relief against continuation of the practices claimed to violate CUTPA, and also statutory attorney's fees and costs. The Society does not seek money damages.

Evidence presented

Because one of the grounds advanced as a reason to dismiss the case is the existence of an arbitration provision in the provider agreements between members of the Society and Oxford, an evidentiary hearing was necessary. Oxford submitted without objection an affidavit signed by Barbara J. Davis, Vice-President for Medical Delivery at Oxford. In an uncontradicted statement, Ms. Davis averred that each Connecticut physician who is part of the network of providers for Oxford enrollees has signed either a Primary Care Physician Agreement or a Consulting Physician Agreement. Both varieties of agreement are referred to as "provider agreements," and both varieties provide, at paragraph 11, that "[n]o civil action concerning any dispute arising under this Agreement shall be instituted before any court, and all such disputes shall be submitted to final and binding arbitration in Connecticut, pursuant to the rules of the American Arbitration Association with one arbitrator." CT Page 16584

Ms. Davis stated at paragraph 6 of her affidavit that "[n]o physicians in Connecticut covered by Provider Agreements with Oxford have filed for arbitration concerning the matters set forth in the Connecticut State Medical Society's Amended Complaint dated June 28, 2001." She further stated that physicians are free to contract with other networks if they contract with Oxford, and that approximately 5,000 out of an estimated 10,340 physicians in Connecticut are covered by provider agreements with Oxford.

The defendant presented evidence, in the form of other paragraphs of Ms. Davis' affidavit, to the effect that physicians located in Connecticut who have signed provider agreements with Oxford treat patients who reside in other states and that some administrative reviews and functions of Oxford at issue in the complaint are performed in states other than Connecticut.

The Society presented no evidence but apparently takes the position that the issue of its standing to allege a direct injury to itself, as opposed to injuries to its members, is to be determined on the basis of the allegations of the amended complaint.

The claims made in the amended complaint

The plaintiff Society sues in two capacities: as a representative of its members and on its own behalf.

In its amended complaint, the Society alleges that Oxford denies and/or delays payments to its physician members who have entered into provider agreements with Oxford and who perform medically necessary health care services to Oxford enrollees. The plaintiff further alleges that Oxford codes members' services in ways that result in lower compensation than is warranted, denies payment for multiple services performed in the same visit, fails to apply upward adjustments for complicated cases that require additional expenditure of time by physicians, makes determinations concerning medical necessity that are not in accordance with applicable medical and legal standards, and fails to provide adequate staffing to process required approvals. (Amended complaint, paras. 10-39.)

As a separate claim, the Society asserts that Oxford's practices regarding Society members' provision of services to Oxford enrollees constitute unfair trade practices in violation of CUTPA.

The Society also alleges that "Oxford's wrongful conduct also causes direct injury to [the Society] because [the Society] has been, and CT Page 16585 continues to be, frustrated by defendant's practices in its efforts to achieve its purpose and [the Society] has been required to devote significant resources to dealing with the issues concerning defendant's unfair practices." (Amended complaint, paras.

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Bluebook (online)
2001 Conn. Super. Ct. 16581, Counsel Stack Legal Research, https://law.counselstack.com/opinion/state-medical-society-v-oxford-hlth-p-no-x01cv0165664s-dec-13-2001-connsuperct-2001.