Vencor Inc. v. National States Insurance Company

303 F.3d 1024, 2002 Daily Journal DAR 10223, 2002 Cal. Daily Op. Serv. 8131, 2002 U.S. App. LEXIS 18287, 2002 WL 2022128
CourtCourt of Appeals for the Ninth Circuit
DecidedSeptember 5, 2002
Docket99-17148
StatusPublished
Cited by17 cases

This text of 303 F.3d 1024 (Vencor Inc. v. National States Insurance Company) is published on Counsel Stack Legal Research, covering Court of Appeals for the Ninth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Vencor Inc. v. National States Insurance Company, 303 F.3d 1024, 2002 Daily Journal DAR 10223, 2002 Cal. Daily Op. Serv. 8131, 2002 U.S. App. LEXIS 18287, 2002 WL 2022128 (9th Cir. 2002).

Opinions

Opinion by Judge BERZON; Concurrence by Judge SNEED.

OPINION

BERZON, Circuit Judge.

This case at first glance concerns a private insurance dispute but, as we shall see, implicates important questions of national health policy for senior citizens. Vencor, Inc. (“Vencor”), an operator of several hospital and nursing home facilities, is the subrogee/assignee of a Medicare supplemental insurance contract between National States Insurance Company (“NSIC”) and Clarence Rollins, a Medicare-eligible individual. In this diversity case, NSIC [1026]*1026paid Vencor Hospital-Phoenix (“Vencor Hospital”) $38,760 for Rollins’ care, the amount that Medicare would have paid. Vencor argues that NSIC did not pay it nearly enough. According to Vencor, Rollins’ supplemental policy obligated NSIC to pay the full amount Vencor would have charged a non-Medicare patient, $171,197.78, so NSIC’s failure to pay the full-billed charges constituted a breach of the contract. The district court, on summary judgment, held that there was no breach of contract. We affirm.

I. BACKGROUND

A. Medicare Coverage and Medigap Insurance

Medicare Part A provides limited inpatient hospital benefits to eligible citizens. During the first 90 days of hospitalization, Medicare pays for all covered services except for coinsurance and certain deductibles. 42 U.S.C. § 1395e(a). A patient hospitalized for more than 90 days may draw upon a non-renewable lifetime reserve of 60 days of additional Medicare coverage. 42 U.S.C. § 1395d; 42 C.F.R. § 409.61(a)(l)-(2). In exchange for receiving payments from Medicare, providers agree to accept that payment, along with any coinsurance or deductible, as payment in full. 42 U.S.C. § ^ceCald).1

Medicare beneficiaries who desire medical coverage in addition to the coverage provided by Medicare can purchase Medicare supplemental insurance policies, known as Medigap polices. See id. § 1395ss(g)(l). These policies provide purchasers with supplementary hospitalization coverage, including coverage of hospitalization costs after the patient exhausts all the hospitalization days Medicare will pay for. See id. §§ 1395ss(g)(l), 1395d.

After the Medicare program had been in effect for a while, Congress became concerned that older citizens were being exploited by the sale of Medigap policies that did not provide the coverage buyers thought they were purchasing. See Social Security Disability Amendments of 1980, Pub. L. No. 96-265, § 507(a) (June 9,1980) (codified at 42 U.S.C. § 1395ss(f)(l)) (requiring evaluation of the effectiveness of state regulation of Medigap policies in limiting marketing and agent abuse and assuring dissemination of sufficient information to enable informed choice). Congress therefore amended the Social Security Act to establish a voluntary certification program for Medigap policies. Through that program, private insurers could receive federal certification for Medigap policies that met specific federal standards. Id. (codified as amended at 42 U.S.C. § 1395ss). At Congress’s request, the National Association of Insurance Commissioners (“NAIC”), an organization of state insurance commissioners, developed the federal standards.

In 1990, Congress went further in protecting Medigap insurance consumers. Instead of its former voluntary program, Congress mandated that Medigap insurers conform their plans to one of ten model Medigap policies, to be developed by the NAIC.2 Omnibus Budget Reconciliation Act of 1990, Pub.L. No. 101-508, § 4351 [1027]*1027(Nov. 5, 1990) (codified as amended at 42 U.S.C. § 1395ss(p)). As amended in 1994, the Medigap statute now provides that no Medigap policy may be issued in a state unless that state has provided “for the application and enforcement” of the 1991 NAIC Model Regulation (“Model Regulation”). Social Security Act Amendments of 1994, Pub.L. No. 103-432, § 171 (Oct. 31, 1994) (codified at 42 U.S.C. § 1395ss(a)(2)(A)).3 See also 42 U.S.C. § 1395ss(p)(4)(A)(ii) (“[T]he Secretary may not provide for or permit the grouping of benefits (or language or format with respect to such benefits) under a medicare supplemental policy seeking approval by the Secretary unless such grouping meets the ... 1991 NAIC Model Regulation. ...”).

Arizona, as required, adopted the Model Regulation. Ariz.Rev.Stat. Ann. § 20-1133(A); Ariz. Admin. Code § R20-6-1101 et seq. An Arizona regulation now provides that Medigap policies issued in the state must comply with a set of uniform standards identical to those in the NAIC Model Regulation. Ariz. Admin. Code § R20-6-1105. Under that regulation, all Medigap policies must contain the basic set of core benefits provided for in the Model Regulation, known as package “A.”4 Id. § R20-6-1105(C); see also 57 Fed. Reg. at 37,991.

Key to this case is the language insurers are required to use in describing the core Medigap benefits provided. In language identical to the Model Regulation, Arizona law requires that the core benefit package include the following coverage:

Upon exhaustion of the Medicare hospital inpatient coverage including the lifetime reserve days, coverage of the Medicare Part A-eligible expenses for hospitalization paid at the Diagnostic Related Group (DRG) day outlier per diem or other appropriate standard of payment, subject to a lifetime maximum benefit of an additional 365 days....

Ariz. Admin. Code § R20-6-1105(C)(3); see also 57 Fed. Reg. at 37,991.5 An Arizona regulation, also in language prescribed by the Model Regulation, requires that all Medigap policies solicited or issued for delivery in Arizona contain certain definitions or terms. Ariz. Admin. Code § R20-6-1103(A). One of those definitions, central to this case, provides: “ ‘Medicare eligible expenses’ shall be de[1028]*1028fined as expenses of the kinds covered by Medicare, to the extent recognized as reasonable and medically necessary by Medicare.” Id. § R20-6-1103(A)(7); see also 57 Fed. Reg. at 37,988.

Further, in compliance with federal law and the Model Regulation, Arizona law requires that insurers provide all applicants for Medigap insurance with a guide that outlines the benefits provided. Ariz. Admin. Code § R20-6-1113(C) & app. B; 42 U.S.C. § 1395s

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Vencor Inc. v. National States Insurance Company
303 F.3d 1024 (Ninth Circuit, 2002)

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303 F.3d 1024, 2002 Daily Journal DAR 10223, 2002 Cal. Daily Op. Serv. 8131, 2002 U.S. App. LEXIS 18287, 2002 WL 2022128, Counsel Stack Legal Research, https://law.counselstack.com/opinion/vencor-inc-v-national-states-insurance-company-ca9-2002.