NEMS, PLLC v. HARVARD PILGRIM HEALTHCARE OF CONNECTICUT, INC., SC 20914

United States District Court for the District of Connecticut

 

Insurance; Whether Connecticut's Surprise Billing Law (SBL) Requires Defendant to Reimburse Out-of-Network Health Care Providers at Greatest of Three Amounts Allowed and Recover Any Deductible, Copayment, or Coinsurance from Insured; If Not, Whether Defendant's Reimbursement Practice Violates SBL; Whether CUTPA Claim Can Be Brought for Actions That Do Not Violate CUIPA but Purportedly Violate SBL. The plaintiff provides emergency medicine physicians to hospitals throughout Connecticut. It brought this action asserting claims for CUPTA based on violations of Connecticut's Surprise Billing Law (SBL), General Statutes 38a-477aa, CUIPA, and violations of the Unfair Billing Practices Act, General Statutes 20-7f (b), arising from the defendant insurer's failure to properly pay for medical services provided to patients who were insured by the defendant. The plaintiff alleged that the defendant refused to pay the difference between the in-network rate and the customary and reasonable rate set forth in the FAIR Health database for services rendered and, instead, passed those differences on to the patient as amounts owed. The plaintiff further alleged that the defendant's action has effectively prevented it from recovering the outstanding balance because any attempt to collect the balance would constitute an unfair trade practice under 20-7f (b). After the defendant removed the action to the United States District Court for the District of Connecticut, the parties cross-moved for summary judgment. The district court observed after a hearing that this action "presents two . . . unsettled areas of Connecticut law. The first, how to interpret the [SBL] and what the statute requires of both insurance providers and healthcare providers . . . . The second is whether a party can maintain a CUTPA claim for a violation of a statute that has not expressly been designated a violation of CUIPA, but that nevertheless regulates insurance conduct." Finding no binding Connecticut authority, the district court certified the following questions, which the Supreme Court accepted pursuant to General Statutes 51-199b: 1. Does Connecticut's SBL, 38a-477aa (b) (3) (A), which provides that "[i]f emergency services were rendered to an insured by an out-of-network health care provider, such health care provider may bill the health carrier directly and the health carrier shall reimburse such health care provider the greatest" of three amounts, require an insurer to fully reimburse an out-of-network health care provider at the greatest of the three amounts for emergency services rendered to its insureds, and then later recover any applicable deductible, copayment, or coinsurance directly from the insured? 2. If not, is the defendant's practice of paying the plaintiff only that amount that exceeds the insured's in-network deductible, copayment, or coinsurance, and leaving the plaintiff to recover the remaining amount directly from the insured, regardless of whether such remaining amount is greater than the amount the insured would have been personally responsible to pay had they visited an in-network provider, a violation of the SBL? 3. Under any interpretation of the SBL, can a plaintiff successfully maintain an action under CUTPA, for actions that do not violate CUIPA, but purport to violate the Surprise Billing Law, because the Surprise Billing Law regulates a specific type of insurance related conduct, under State v. Acordia, 310 Conn. 1, 73 A.3d 711 (2013)?