Opinion ID: 33400
Heading Depth: 3
Heading Rank: 1

Heading: Ochsner's Status as a Health Maintenance Organization

Text: 11 To gain the benefit of § 22:663, Arana must first demonstrate that it covers OHP and the health benefits OHP provides to HMO plan beneficiaries like Arana. The statute regulates group accident, health and hospitalization insurance policies that are issued by any insurer doing business in this state. LA.REV.STAT. § 22:663. According to the Louisiana Insurance Code, an insurer includes every person engaged in the business of making contracts of insurance, other than a fraternal benefit society. LA.REV.STAT. § 22:5(10). OHP is a health maintenance organization, however, not an insurer, and Louisiana law has carefully identified the Insurance Code provisions that apply to HMOs. Thus, [a] health maintenance organization is an insurer but only for the purposes enumerated in R.S. 22:2002(7). Id. (emphasis added). Section 22:2002(7) of the Insurance Code, in turn, deems 12 [a] health maintenance organization... to be an insurer for the purposes of R.S. 22:213.6 and 213.7, Part XVI, comprised of R.S. 22:731 through 774, Part XXI-A, comprised of R.S. 22:1001 through 1015, and Part XXVI-B, comprised of R.S. 22:1241 through 1247.1, of Chapter 1 of this title, 13 and states that [a] health maintenance organization shall not be considered an insurer for any other purpose.  LA.REV. STAT. 22:2002(7) (emphasis added). Because this list of provisions omits Part XIV, which encompasses § 22:663, OHP is not an insurer subject to the provisions of § 22:663. This conclusion comports with prior decisions of the Louisiana state courts which have found that the Louisiana legislature intended to treat HMOs as insurers only for selective and limited purposes. Tucker v. Ochsner Health Plan, 674 So.2d 1052, 1055 (La.App. 2 Cir. 1996) (holding that an HMO is not an insurance company for purposes of a statute granting special venue provisions for insurance claims); Crawford v. Blue Cross and Blue Shield of Louisiana, 814 So.2d 574, 580 (La.App. 4 Cir.2001) (declining to follow Tucker on the grounds that Blue Cross was an insurer rather than an HMO). 2 14 Arana nonetheless argues that OHP is subject to § 22:663 because § 22:232(13) defines health and accident insurance to include coverages provided by health maintenance organizations and therefore this provision functions as an additional exception to the general bar on treating HMOs as insurers under Louisiana law, thus making § 22:663 applicable to OHP. The problem with Arana's argument is that the scope of the definition he cites is limited by a parallel provision within the same code section. Section 22:232(19) makes clear that HMOs are insurers within that code section, but only  for the purposes of this Part.  See LA.REV.STAT. § 22:232(13); LA.REV.STAT. § 22:232(19) (emphasis added). The Part referred to in§ 22:232 is Part VI-A, which specifically applies only to the state-backed Louisiana Health Plan. Thus, while Arana is correct that the combination of § 22:232(13) and § 22:232(19) functions as an additional exception to the general bar against treating HMOs as insurers under Louisiana law, it does not allow HMOs to be treated as insurers under § 22:663, which is contained in Part XIV — a separate section of the Louisiana Insurance Code which is unaffected by the definitions contained in § 22:232. 15