U.S. Healthcare, Inc. v. Curiale

162 Misc. 2d 833, 615 N.Y.S.2d 239, 1994 N.Y. Misc. LEXIS 279
CourtNew York Supreme Court
DecidedApril 26, 1994
StatusPublished
Cited by2 cases

This text of 162 Misc. 2d 833 (U.S. Healthcare, Inc. v. Curiale) is published on Counsel Stack Legal Research, covering New York Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
U.S. Healthcare, Inc. v. Curiale, 162 Misc. 2d 833, 615 N.Y.S.2d 239, 1994 N.Y. Misc. LEXIS 279 (N.Y. Super. Ct. 1994).

Opinion

OPINION OF THE COURT

Carol H. Arber, J.

Petitioner U.S. Healthcare, Inc. (USH) commenced this proceeding pursuant to CPLR article 78 for an order annulling the opinion and decision dated September 30, 1993 issued by the Superintendent of Insurance (Superintendent) on the ground that the decision exceeded the Superintendent’s statutory authority and was arbitrary and capricious. The Superintendent argues that the petition for review under CPLR article 78 is without merit and should be dismissed.

Petitioner, USH, has a certificate of authority as a Health Maintenance Organization (HMO) pursuant to article 44 of the Public Health Law. Petitioner provides health care services to persons who subscribe to one of petitioner’s plans and charges these persons a fixed rate premium (the premium).

Respondent, Salvatore R. Curíale, is the Superintendent of Insurance of the State of New York.

Pursuant to article 44 of the Public Health Law, HMOs, such as petitioner, are regulated within the State of New York by the Commissioner of Health. (Public Health Law § 4400 et seq.) In keeping with his supervisory function the Superintendent must review all contracts entered into between the HMO and its subscribers. (Public Health Law § 4406 [1].) Among other things, these contracts set the premiums which the HMO is permitted to charge its subscribers. In reviewing these contracts the Superintendent must apply the procedures and standards set out in article 43 of the Insurance Law. (Public Health Law § 4406 [1]; see also, Mem of Assembly Standing Comm on Health, 1976 NY Legis Ann, at 240.)

Article 43 of the Insurance Law, in turn, provides a detailed administrative scheme for review and approval of contracts [835]*835and the premiums sought to be charged. (Insurance Law § 4301 et seq.) Under this scheme, the HMO is required to apply to the Superintendent whenever it seeks a modification of its existing premiums and the Superintendent must approve any increase in premium rates before it can be imposed. Insurance Law § 4308 (c) (2) requires that before the Superintendent may approve any such application, a public hearing must be held and notice of the hearing must be published in at least two newspapers of general circulation. After the hearing has been completed, the Superintendent must then "render a written decision determining whether the [application] shall become effective as filed, shall become effective as modified, or shall be disapproved.” (Insurance Law § 4308 [c] [3].)

On or about June 30, 1993, USH filed an application with the Superintendent seeking an increase in premium rates for the period October 1, 1993 through September 1, 1994. Petitioner based this application upon a series of actuarial assumptions about health care costs and revenues. Pursuant to Insurance Law § 4308, a public hearing was held to review the application before officials of the New York State Insurance Department on August 17, 1993. During the hearing, no one from the New York State Insurance Department voiced any objection to the requested premium rate increase; USH was not given notice that anything but a premium rate increase would be reviewed. On September 30, 1993, the Superintendent issued a decision which disapproved USH’s request for a subscriber rate increase; in addition, the Superintendent directed that the rates then in effect be reduced by an average of 3.9%.

The Superintendent based his decision to roll-back USH’s rates on a variety of factors including that (1) USH’s actuarial assumptions were too conservative, (2) USH might receive the benefit of litigation settlements, and (3) USH’s projected rate of return exceeded the usual rate for similar Health Maintenance Organizations.

In this proceeding USH challenges and seeks to annul the Superintendent’s determination on the basis that it is contrary to law, arbitrary and capricious. Petitioner’s first assertion is that the Superintendent lacks power or authority to regulate changes in premium rates for profit-making HMOs.

In considering this argument, it is noteworthy that while petitioner argues that the Superintendent lacks authority, on [836]*836no less than eight separate occasions prior to 1993, petitioner made premium rate applications to the Superintendent pursuant to the procedures set forth in article 43 of the Insurance Law. The Superintendent rejected one of these applications and modified another. At no time during these prior applications and review procedures did the petitioner ever question let alone object to the Superintendent’s authority to regulate HMO premium rates. Only now, when this process has resulted in an unfavorable decision does petitioner attempt to make an issue of the Superintendent’s authority.

An examination of both the legislation and its history provides ample basis for concluding that the regulatory scheme was intended to cover organizations like USH.

Petitioner, as an HMO, is regulated by article 44 of the Public Health Law. (See, Public Health Law § 4400 et seq.) Part of this regulatory scheme requires that the "contract between a [HMO] and an enrollee shall be subject to regulation by the superintendent as if it were a health insurance subscriber contract. ” (Public Health Law § 4406 [1] [emphasis added].) Such "health insurance subscriber contracts” are, in turn, governed by article 43 of the Insurance Law, which applies to "contracts] to furnish medical expense indemnity.” (Insurance Law § 4301 [f].) Thus, the Superintendent must follow the procedures set forth in article 43 of the Insurance Law for regulating health insurance contracts.

In making the argument that the Superintendent may not apply the procedures of article 43 in regulating the HMO contract petitioner relies upon language in subdivision (2) of Public Health Law § 4406 which states that "[n]othing in this section shall be construed to require a health maintenance organization in its provision of a comprehensive health services plan to meet the requirements of an insurer under the insurance law.” (Emphasis added.) However, by its own terms, this language applies to the actual "provision” of services once a HMO and enrollee have entered into a contract; this language does not apply to the Superintendent’s regulation of that contract. The fact that this subdivision is located within section 4406 makes this point abundantly clear: subdivision (2) directly follows subdivision (1), which requires that the Superintendent regulate HMO contracts as if they were health insurance subscriber contracts. Thus, to read subdivision (2) as exempting HMO contracts, as well as the HMO’s provision of services, from the requirements of the Insurance Law would result in rendering subdivision (1) a nullity.

[837]*837In the legislative history of the statute, the Memorandum of the Assembly Standing Committee on Health accompanying the legislation noted the need to allow HMOs to provide services without being hampered by the strict requirements of the State’s Insurance Law; at the same time, the Memorandum states that the HMO contract itself must nonetheless be regulated by the State’s Insurance Department, rather than the Department of Health. (1976 NY Legis Ann, at 240.) Accordingly, the applicable law makes it clear the Superintendent has the authority to review and set HMO premium rates.

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162 Misc. 2d 833, 615 N.Y.S.2d 239, 1994 N.Y. Misc. LEXIS 279, Counsel Stack Legal Research, https://law.counselstack.com/opinion/us-healthcare-inc-v-curiale-nysupct-1994.