Wooley v. Lucksinger

61 So. 3d 507, 2011 La. LEXIS 706, 2011 WL 1205136
CourtSupreme Court of Louisiana
DecidedApril 1, 2011
DocketNos. 2009-C-0571, 2009-C-0584, 2009-C-0585, 2009-C-0586
StatusPublished
Cited by293 cases

This text of 61 So. 3d 507 (Wooley v. Lucksinger) is published on Counsel Stack Legal Research, covering Supreme Court of Louisiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Wooley v. Lucksinger, 61 So. 3d 507, 2011 La. LEXIS 706, 2011 WL 1205136 (La. 2011).

Opinions

CLARK, Justice.1

| i>This matter comes before the court pursuant to four writ applications filed by the plaintiffs, consolidated here for review. At issue are questions of fact and law [526]*526arising in tort and contract causes of action.

In the trial court, the Louisiana Commissioner of Insurance filed three separate lawsuits against several defendants on behalf of a failing health maintenance organization. One of the lawsuits sounded in contract, the other two sounded in tort. The Oklahoma Commissioner of Insurance and a receiver appointed by the Texas Commissioner of Insurance intervened as plaintiffs in the tort cases on behalf of affiliated health maintenance organizations, organized and doing business in those states, which had similar tort causes of action against the defendants. The three lawsuits — which alleged causes of action in negligence, negligent misrepresentation, conspiracy, fraud, breach of fiduciary duty, unfair or deceptive acts or practices, and contractual liability — were consolidated. Prior to trial, all of the defendants, except one, settled with the plaintiffs. The consolidated matters were tried to both the bench and jury against the sole remaining defendant. Both the judge and jury found in favor of the plaintiffs on the tort and contract causes of action and awarded damages.

The defendant appealed. Finding errors of law which interdicted both the bench and jury findings of fact in the tort claims, the court of appeal conducted a de novo review of the record and reversed the judgments which had been rendered in favor of the plaintiffs and the awards of damages. The court of appeal, in a separate opinion, affirmed the liability of the defendant in the contract matter, but amended the trial court’s judgment to reduce the amount of the award. This court granted certiorari to determine the correctness of the court of appeal’s rulings.

FACTS

At the outset we acknowledge this court’s recitation of the facts is very Isdifferent from those discussed in the court of appeal opinion which we now review. Our study of the record convinces us the court of appeal fundamentally misunderstood the facts underlying these complex business transactions and the issues presented. However, we believe the court of appeal’s confusion of the issues and failure to understand the facts are somewhat understandable. The record of these three consolidated cases is extensive, consisting of the pleadings in all three cases, a large number of documents and exhibits, and transcripts from numerous pretrial hearings and a lengthy trial.2 The [527]*527business transactions, and their accompanying accounting treatment, are unusual. Most important in the consideration of the reasons for the court of appeal’s failure of understanding is the fact that what is at the core of these matters is a sophisticated deception which fooled even those individuals tasked with regulating the type of transaction at issue.

The operative facts of the tortious conduct to be described are common to all of the claims asserted by the plaintiffs. From the evidence presented at trial, the judge and jury could find the following facts.

Corporate History

Prior to 1997, Foundation Health Corporation (“Foundation”), a Delaware corporation with its principal place of business in California, owned all of the stock [4of three health maintenance organizations (“HMOs”). These subsidiary HMOs were known as Foundation Health, a Louisiana Health Plan, Inc., a Louisiana corporation operating in the State of Louisiana (“the Louisiana HMO”); Foundation Health, an Oklahoma Health Plan, Inc., an Oklahoma corporation operating in the State of Oklahoma (“the Oklahoma HMO”); and Foundation Health, a Texas Health Plan, Inc., a Texas corporation operating in the State of Texas (“the Texas HMO”). In 1997, Health Systems International acquired Foundation. Thereafter, Health Systems International, Inc. changed its name to Foundation Health Systems, Inc. and is now known as Health Net, Inc. (“Health Net”).3 In this way, Health Net acquired sole ownership of the three HMOs.

The HMOs

Almost from the beginning, Health Net wanted to divest itself of the HMOs. These three HMOs were the smallest plans owned by Health Net, consisting of approximately 75,000 members combined, and did not fit Health Net’s overall business strategy. Health Net wanted to focus on its three main business units — on the West Coast in California; on the East Coast in New York, New Jersey and Connecticut; and on its contracts with the Department of Defense. Worse, the HMOs were an immense money drain on Health Net because their insurance premiums were underpriced; their contracts with insurance providers were too low. From 1993 through 1999, Health Net and its predecessor companies were required to infuse $50 million in capital contributions in order to keep these insurance companies in regulatory compliance in their respective states.

Soon after Health Net acquired the HMOs in 1997 through the above-described mergers, its then-CEO, Dr. Hasan, decided Health Net should not finance the HMOs 1 Bon a continuing basis. Dr. Hasan felt all three states were bad regulatory environments and directed his senior management to begin to “wind down” the plans.

Necessary Insurance Terms

It is important at this juncture to examine some terms and concepts necessary to understand the facts and the claims of the parties. These HMOs, all insurance entities, were regulated by the state insurance departments in their respective states; namely, the Louisiana Department of Insurance (“La-DOI”), the Oklahoma De[528]*528partment of Health (“Ok-DOH”), and the Texas Department of Insurance (“Tx-DOI”). The insurance industry is intensely scrutinized and regulated in the several states due to the public policy issues inherent within this type of business. The states have an interest both in ensuring their citizens obtain proper insurance to protect health and safety and in determining the companies which provide insurance policies appropriately utilize the insurance premiums which their citizens pay. This conservative approach to insurance regulation is reflected in the accounting method used for this type of business.

The proper method of accounting for the insurance industry is based on statutory accounting principles, or SAP. This method of accounting is more conservative than the one used for most businesses, known as generally accepted accounting principles, or GAAP. This more conservative accounting treatment is consistent with the states’ protection of the public through regulation of this industry. In addition, insurance companies and their accountants must follow the rules of the National Association of Insurance Commissioners, known as the NAIC rules.

Insurance policies, or contracts, are sold for a particular amount of money, or a premium. Sometimes, an insurance company has to pay out for a claim more money than was received as a premium. In the course of its business, an insurance company | (¡depends upon an actuary or accountant to determine the statistical probability of this premium deficiency. In order to cover this possible future cost, insurance companies set aside a reserve amount of money. In accounting terms, this is known as a premium deficiency reserve, or PDR, which is booked on a balance sheet as a liability. A PDR is also sometimes referred to as a “loss contract reserve.”

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61 So. 3d 507, 2011 La. LEXIS 706, 2011 WL 1205136, Counsel Stack Legal Research, https://law.counselstack.com/opinion/wooley-v-lucksinger-la-2011.