TIG Specialty Insurance v. Koken

855 A.2d 900
CourtCommonwealth Court of Pennsylvania
DecidedAugust 3, 2004
StatusPublished
Cited by16 cases

This text of 855 A.2d 900 (TIG Specialty Insurance v. Koken) is published on Counsel Stack Legal Research, covering Commonwealth Court of Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
TIG Specialty Insurance v. Koken, 855 A.2d 900 (Pa. Ct. App. 2004).

Opinion

OPINION BY

Judge COHN.

This case requires us to evaluate the language of an exclusion in a Directors’ and Officers’ Liability insurance policy (D & 0 Policy) to determine if it precludes insurance coverage for a claim brought by the Pennsylvania Insurance Commissioner in her role as Statutory Liquidator (Liquidator) against the directors and officers of an insurance company.

The case is related to a statutory liquidation proceeding 1 involving an insolvent insurer/medical benefits coordinator named Health Resources Management Health Plans (PA), Inc. (HRM Health Plans (PA) or HRMPA). The Liquidator filed a separate action against the Directors and Officers of HRMPA (“D & O Action”), alleging various breaches of their fiduciary duties and seeking to recover damages. Health Resources Management, Inc. (HRM) the parent company of HRMPA, had purchased a Directors’ & Officers’ Liability Insurance Policy from TIG Specialty Insurance Company (TIG) to protect the Directors and Officers of both companies. TIG and the Directors and Officers seek a declaratory judgment from this Court as to whether the D & O Policy provides insurance coverage for the claims in the D & O Action. Before the Court are four motions for judgment on the pleadings filed by TIG and various Officers and Directors of HRMPA.

FACTUAL BACKGROUND 2

HRM and HRMPA Business Relationship

In 1993, the Pennsylvania Department of Public Welfare (DPW) 3 entered into a Healthchoices agreement with Oxford Health Plans, Inc. (Oxford), a certified Pennsylvania HMO (health maintenance organization), 4 under which Oxford provided medical benefits to Pennsylvania Medicaid recipients in Philadelphia, Bucks, Chester, Delaware and Montgomery Counties. In 1998, Oxford entered into an agreement (Oxford Agreement) with HRM, a Minnesota Corporation, to provide third party administrative services for Oxford’s part of the Healthchoices agreement. Under this agreement, the administrative fees would not exceed $20 per Medicaid recipient, of which there were approximately 73,000 per month. The Oxford Agreement was for a five year period, beginning April 15,1998.

In 1999, HRM acquired Oxford by purchasing all of Oxford’s stock. HRM changed Oxford’s name to HRM Health Plans (PA), Inc. HRMPA thus, was a wholly owned subsidiary of HRM that was separately incorporated with its statutory office and principal place of business in Philadelphia, PA. As a separate corporation, it maintained its own corporate officers and directors. Nevertheless, most of HRMPA’s officers and directors were also officers or directors of HRM. 5

*904 HRMPA had a Healthchoices agreement with DPW. As had Oxford, HRMPA also entered into an administrative service agreement with HRM, effective January 1, 1999 (HRMPA Agreement). As with the Oxford agreement, HRM agreed to provide all administrative and managerial services for HRMPA. This managerial agreement remained in effect for all times relevant to this litigation.

As an HMO, HRMPA was subject to regulation under Pennsylvania insurance laws. Under these laws, the Pennsylvania Insurance Commissioner regulates covered organizations ensuring each has sufficient assets to remain solvent. These laws direct that, in instances of a covered corporation facing insolvency, the Insurance Commissioner may petition this Court to place the insurer into rehabilitation, through which the Insurance Commissioner, acting as a Rehabilitator, works with the insurer to restore solvency. If rehabilitation efforts prove unsuccessful, the Insurance Commissioner may petition the Court to enter the insurer into liquidation, at which time the Insurance Commissioner, in her role as Liquidator, is charged with marshalling the insurer’s assets for distribution to creditors.

In 2001, HRMPA had difficulty fulfilling its financial obligations, resulting in the Insurance Commissioner asserting control over HRMPA under the rehabilitation provisions of the Act. The instant proceeding arises from the purported actions and inac-tions of HRMPA Directors and Officers during the period from January 1, 1999, until the Insurance Commissioner asserted control over the company in September 2001.

Liquidator’s Action to Recoup Assets

Within a few weeks of HRMPA entering rehabilitation, the Insurance Commissioner petitioned this Court to have HRMPA placed into liquidation. This Court granted that petition on September 20, 2001, effective October 1, 2001. In her role as Statutory Liquidator, the Insurance Commissioner filed a complaint with the Commonwealth Court at Docket Number 594 M.D. 2002, seeking to recover from HRMPA’s Directors and Officers, the lost value of HRMPA’s assets which allegedly resulted from breaches of their fiduciary duties in their management of HRMPA (D & O Action).

In the D & O Action, the Liquidator first argues that HRMPA allowed HRM to increase its management fee by 50% without requiring HRM to provide any business justification for doing so. This argument is based upon a provision in the HRMPA Agreement, in which HRMPA agreed to pay HRM actual costs for administering HRMPA; HRM was required to make regular reconciliations between the amounts paid by HRMPA, and the actual expenses incurred by HRM. The Liquidator alleges these reconciliations were not performed in a meaningful way. She argues that HRMPA Officers and Directors, in the absence of any meaningful reports, breached their fiduciary duties by allowing HRMPA to pay fees that were 50% greater than what Oxford paid, without HRM showing any connection between the greater fees and its actual costs of administering Healthchoices. The Liquidator alleges that “during their respective tenures, the Defendants, as HRMPA’s officers and/or directors, knew or should have known that the management fees were grossly excessive and disproportionate to the fair market value of services that HRM provided.... ” (Amended Complaint at 15, ¶ 63).

The Liquidator also alleges that the Defendants approved substantial payments from HRMPA to HRM that were not, in any matter, related to fees associated with the HRMPA agreement. She asserts that *905 in 2000, HRM “transferred funds between its accounts and HRMPA’s accounts at will ... [using] these ill-gotten funds to bolster other of its subsidiaries, to fatten its own revenues ... and to satisfy HRM’s corporate obligations.” (Amended Complaint at 16-17, ¶ 69). She further alleges that HRMPA transferred $8.5 million to HRM, in excess of HRM’s charges to HRMPA, charges that the Liquidator has previously alleged were themselves exorbitant. She maintains that HRMPA’s Officers and Directors breached their fiduciary duties to HRMPA by failing to pay attention to HRMPA’s finances, thus, allowing these transfers to occur. The Liquidator also alleges that “the Combination of excessive management fees and additional ‘extra-contractual’ transfers proved to be devastating to HRMPA.

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Cite This Page — Counsel Stack

Bluebook (online)
855 A.2d 900, Counsel Stack Legal Research, https://law.counselstack.com/opinion/tig-specialty-insurance-v-koken-pacommwct-2004.