Virginia Academy of Clinical Psychologists v. Group Hospitalization & Medical Services, Inc.

878 A.2d 1226, 2005 D.C. App. LEXIS 375, 2005 WL 1653872
CourtDistrict of Columbia Court of Appeals
DecidedJuly 14, 2005
Docket03-CV-392
StatusPublished
Cited by59 cases

This text of 878 A.2d 1226 (Virginia Academy of Clinical Psychologists v. Group Hospitalization & Medical Services, Inc.) is published on Counsel Stack Legal Research, covering District of Columbia Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Virginia Academy of Clinical Psychologists v. Group Hospitalization & Medical Services, Inc., 878 A.2d 1226, 2005 D.C. App. LEXIS 375, 2005 WL 1653872 (D.C. 2005).

Opinion

STEADMAN, Senior Judge.

This lawsuit arose from the marketing and management of mental health care benefits under the Capital Choice Triple Option (“Capital Choice”) health insurance plan. The plaintiffs consisted of three groups; namely, two individual subscribers to the Capital Choice Plan, six clinical psychologists who provided services under the plan, and a professional association of clinical psychologists. They sued the ap-pellee insurance companies and insurance benefit administrators for, inter alia, common law fraud based on two alleged misrepresentations about the scope of mental health coverage under the Capital Choice plan.

The principal issues on appeal are whether the trial court erred in (1) granting summary judgment on the common law fraud count; and (2) denying a motion to amend the complaint to include a claim for fraud under the District of Columbia Consumer Protection Procedures Act. 1 We affirm.

*1230 I. Facts

Marjorie Burdetsky switched jobs in the fall of 1997 and had to choose a health insurance provider for herself and her husband, Joaquin Araya, through her new employer, the Arlington County, Virginia government. At the time, Araya was receiving mental health treatment. Burdetsky’s options included three types of plans from Blue Cross Blue Shield of the National Capital Area (Blue Cross) 2 : a managed care (HMO) option, preferred provider organization (PPO) option, or an indemnity plan. 3 Blue Cross also offered a hybrid insurance plan, the Capital Choice Triple Option plan, under which Burdetsky and her husband could choose among the three different types of insurance coverage (HMO, PPO, and indemnity) each time they sought medical care. Burdetsky also had the choice of a plan offered by another insurance company, Kaiser Permanente. Burdetsky chose the Capital Choice Triple Option plan, which had lower co-payments than the Blue Cross PPO or indemnity plans and more mental health benefits than the Kaiser Permanente plan. 4 Burdetsky completed an enrollment form on December 1, 1997, and her insurance coverage became effective on January 1, 1998.

Health Management Strategies International, Inc. (“HMS”), as the administrator of mental health benefits for the Capital Choice plan, was charged with creating and maintaining the mental health provider panel for the Capital Choice plan and assessing the needs of subscribers for services under the plan. By contracting to be in HMS’ network, providers agreed to see patients with Capital Choice insurance and comply with administrative procedures required by HMS. The providers were then paid according to a contracted-for fee schedule.

In the fall of 1997, while Burdetsky was choosing among her health insurance options, HMS implemented a new fee schedule that reduced the amount providers were paid by the insurance company for their services. On November 24, 1997, HMS mailed a letter to every provider on the mental health panel explaining that there would be a 30-40% cut in their reimbursement rates effective January 1, 1998. Approximately 100 mental health professionals out of a total panel of approximately 1000 providers left the provider network as a result of the rate cut. The six clinical psychologists who are appellants here were among those who had contracted with HMS to provide mental health services to patients covered by the Capital Choice plan and were affected by the rate cut.

*1231 Before being covered under the Capital Choice plan, Burdetsky’s husband, Joaquin Araya, had already been receiving treatment beginning in July 1997 from Dr. John Gualtieri, a clinical psychologist and a provider appellant, for depression and post-traumatic stress disorder. Dr. Gualtieri was listed as both an HMO and a PPO provider in the Capital Choice plan materials. In January 1998, Dr. Gualtieri’s treatment of Araya continued, now under the HMO portion of the new Capital Choice insurance plan. The plan also offered the opportunity to receive services from Dr. Gualtieri under the PPO coverage at a higher rate of co-payment than under the HMO. After February 6, 1998, Araya’s treatment with Dr. Gualtieri continued but under the PPO coverage, despite that fact that the insurance benefits booklet relating to the Capital Choice plan stated that mental health treatment was covered in full under the HMO for “up to 52 visits” per calendar year. 5

The instant litigation began in December 1998 when a wide-ranging nine-count complaint was filed by all appellants alleging two counts of fraudulent misrepresentation, four counts of breach of contract, two counts of breach of implied contract, and one count of tortious interference with a business relationship. The claims and their resolution in the course of the extended trial court proceedings were as follows:

Count Description of Plaintiff Group Resolution Cause of Action
One Fraudulent Burdetsky & Araya Summary judgment for Misrepresentation defendants
Two Breach of Contract Burdetsky & Araya Settled
Three Breach of Implied Burdetsky & Araya Settled Contract
Four Breach of Contract Psychologists Abandoned (patient care)
Five Breach of Implied Dr. Gualtieri, Summary judgment for Contract Dr. Chilstrom defendants
Six Breach of Contract Dr. Potter • Summary judgment for (wrongful defendants termination)
Seven Breach of Contract Psychologists Settled (implementation of rate reduction)
Eight Fraudulent Dr. Potter Summary judgment for Misrepresentation defendants
Nine Tortious Dr. Gualtieri, Summary judgment for Interference with Dr. Chilstrom, defendants Business Araya Relationship

The only resolutions of these claims chai-lenged on appeal relate to the grant of summary judgment on Burdetsky and *1232 Araya’s common law fraud claim and the refusal to allow an amendment to the complaint, described in the following paragraph.

The common law fraud claim filed in December 1998 by Burdetsky and Araya was based on' two specific instances of alleged misrepresentation by appellees: (1) the informational materials for the plan say that the HMO will cover up to 52 medically necessary sessions but Araya received only 5 HMO covered sessions under the Capital Choice plan before being induced to switch to the PPO coverage; and (2) the size and stability of the panel of providers was falsely represented because appellees had just embarked on a rate cut that consumers were not warned about when they were recruited with materials that included the large provider list. Appellants unsuccessfully sought leave to amend the complaint in May 2001 to include two claims under the D.C.

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Bluebook (online)
878 A.2d 1226, 2005 D.C. App. LEXIS 375, 2005 WL 1653872, Counsel Stack Legal Research, https://law.counselstack.com/opinion/virginia-academy-of-clinical-psychologists-v-group-hospitalization-dc-2005.