Court Opinion

ID: 9588347
Source: CourtListenerOpinion
Date Created: 2023-08-21 23:33:17.117333+00
Date Added: 2024-06-11T18:00:58.341012
License: Public Domain

Andrews, Presiding Judge,
dissenting.
I respectfully dissent.
Because the health care plan provided by the Hospital Authority of Houston County (HHC) unambiguously excludes coverage for the medical procedure at issue, the trial court erred by ruling that HHC was estopped from denying coverage.
In July 2003, William Bohannon was rediagnosed with recurrent metastatic renal cell carcinoma.16 It is undisputed that Mr. Bohannon is covered under HHC’s managed health care plan (the HHC plan) under family coverage provided to his wife, an HHC employee. After the 2003 rediagnosis, the plan paid for extensive treatment Mr. Bohannon received for his illness at cancer treatment centers at M. D. Anderson Hospital in Houston and at Duke University Medical Center. Unfortunately, these treatments were not able to control or cure the cancer.
In December 2003, Mr. Bohannon sought approval from the HHC plan for coverage of a promising medical procedure known as a mixed chimerism allogeneic stem cell transplant to be performed in the Duke University bone marrow/stem cell transplant program. In 2003, the third-party administrator for the HHC plan was Blue Cross Blue Shield of Georgia. Under its agreement with HHC, Blue Cross drafted documents showing the coverage limits for benefits provided by the HHC plan and made determinations as to whether or not the HHC plan covered various claims for benefits. Although Blue Cross “pre-certified” Mr. Bohannon for testing at Duke University related *105to possible treatment, Blue Cross never gave Mr. Bohannon “preauthorization” under the HHC plan indicating that there was coverage for the stem cell transplant. After Blue Cross reviewed the claim and a peer review process was completed, Blue Cross determined on December 18, 2003 that the stem cell transplant sought by Mr. Bohannon was not covered by the HHC plan because it was an experimental or investigational treatment, which was excluded from coverage by the plan.
Shortly after Blue Cross made that determination, HHC terminated Blue Cross as the third-party administrator of its plan and hired Secure Health as the new third-party administrator of the HHC plan effective January 1,2004. At that point, HHC and Secure Health had not yet signed off on a new health care plan document for 2004, so the existing 2003 Blue Cross drafted plan document remained as the HHC plan for the first two months of 2004 and was administered by Secure Health.17 In January 2004, HHC asked Secure Health to fully review Mr. Bohannon’s request for coverage of the stem cell transplant giving no deference to Blue Cross’s earlier denial of coverage. Upon review by Secure Health, including additional independent peer review, Secure Health determined that the stem cell transplant was not experimental or investigational as defined by the HHC plan, and therefore the procedure was not excluded from coverage under the plan on that basis. However, Secure Health further determined that the stem cell transplant at issue was otherwise excluded from coverage under the express terms of the HHC plan.
As the Secure Health claim review determined, the HHC plan provides coverage for medically appropriate transplants of the type sought by Mr. Bohannon, but only if the transplant is for the treatment of a condition specifically listed in the HHC plan. Because renal cell carcinoma is not one of the listed conditions, the HHC plan expressly excludes the transplant sought by Mr. Bohannon for that condition. Furthermore, the HHC plan states that no coverage is provided for “[a]ny transplant not specifically listed as covered.” Pursuant to the Secure Health claim review, Mr. Bohannon was finally informed by HHC on February 17,2004 that the HHC plan did not cover the stem cell transplant. In March 2004, Mr. Bohannon filed a petition in the Superior Court of Houston County seeking a ruling that, under the circumstances, the HHC plan was required to provide coverage.
*106After hearing testimony about the claim review process and the denial of coverage, the trial court ruled as follows:
When the coverage denial on the basis of “experimental/investigational” was made known to . . . [Mr. Bohannon], rather than pursuing some other possible avenue of treatment or financing, [he] sought to appeal the finding of experimental treatment, succeeded in doing so, and now is told that the procedure is simply not in the coverage provided by the plan. This Court will not now allow the plan to stand on such a position at this late date when the provisions and coverages of the plan were never made available and when the life of the patient now hangs in the balance. [HHC] is hereby estopped from denying coverage and must immediately provide for the recommended treatment at Duke Medical Center.
HHC appealed from this ruling. Although there is evidence that Blue Cross mishandled the initial review process and delayed the denial of coverage when Mr. Bohannon deserved a timely and accurate determination, the record clearly shows there was no coverage under the HHC plan for a stem cell transplant to treat renal cell carcinoma. Nothing in the record supports the conclusions reached by the trial court and the majority that HHC was estopped to deny coverage because of the manner in which the claim was denied or because Mr. Bohannon had no notice of coverage limitations under the HHC plan.
When Blue Cross became the third-party administrator for the HHC plan effective January 1, 2003, a health care plan went into effect on that date which provided for coverage benefits and exclusions from coverage under a network of health care providers assembled by Blue Cross. This was the same plan that paid for Mr. Bohannon’s treatment in 2003 at M. D. Anderson and Duke University Medical Center. Both HHC and Blue Cross representatives testified that they signed a Group Master Application document in October 2002 by which the basic Blue Cross PPO health care plan was adopted as the HHC plan effective January 1, 2003, except for changes to the basic PPO plan made by HHC and attached to the application. Accordingly, the application with attached changes to the coverages and exclusions set forth in the basic Blue Cross PPO plan were the documents which comprised the 2003 HHC plan. Over the course of 2003, three modifications were made to the HHC plan, none of which had anything to do with coverage for stem cell transplants. Although one of Blue Cross’s duties as the third-party administrator was to prepare a booklet for employees summarizing the 2003 HHC plan, the booklet was not finalized until late December 2003 and was *107not sent to employees at that time because of the change in third-party administrators. However, before the HHC plan went into effect on January 1, 2003, HHC sent a letter to all its covered employees, including Ms. Bohannon, informing them of the change to the Blue Cross PPO network and various health plan changes, and directing employees with questions about the plan to call the HHC human resources office. Ms. Bohannon testified that she first requested a copy of the written HHC plan after she and her husband received a denial of coverage letter from Blue Cross on December 22, 2003. Pursuant to that request, she received a copy of the Blue Cross prepared booklet, which showed that the HHC plan excluded coverage for stem cell transplants for the treatment of renal cell carcinoma.
The record shows that the HHC plan, whether for 2003 (under Blue Cross) or for 2004 (under Secure Health), unambiguously excluded coverage for a stem cell transplant for the treatment of renal cell carcinoma. Even though the HHC plan was a contract of adhesion written wholly by HHC and its third-party administrator (as the majority notes), the unambiguous provisions of the contract must be applied as written and are not subject to contrary construction by this Court.18 Rossville Fed. S & L Assn. v. Ins. Co. of North America, 121 Ga. App. 435, 438 (174 SE2d 204) (1970); Nationwide Mut. Fire Ins. Co. v. Tomlin, 181 Ga. App. 413, 414-416 (352 SE2d 612) (1986). Moreover, the doctrine of estoppel based on the conduct of HHC or its third-party administrator cannot be applied to require coverage for a medical procedure clearly excluded from coverage by the HHC plan. Caribbean Lumber Co. v. Phoenix Assurance Co. &c., 227 Ga. App. 236, 240-241 (488 SE2d 718) (1997). “Neither waiver nor estoppel can be used to create a liability not created by the contract and never assumed by [HHC] under the terms of the [health care plan].” (Citation and punctuation omitted.) Washington v. Hartford Accident & Indem. Co., 161 Ga. App. 431, 432 (288 SE2d 343) (1982). Accordingly, the fact that HHC or Blue Cross may have initially denied coverage for the wrong reason provides no basis for finding that HHC was estopped to deny clearly excluded coverage.
Finally, there is no basis for the majority’s conclusion that HHC was barred from enforcing the coverage limitation because Mr. Bohannon had no notice of the limitation or because he was denied an opportunity to review the HHC plan. The record shows that HHC adopted a health care plan with Blue Cross as the third-party administrator effective January 1, 2003. HHC in formed its covered *108employee, Ms. Bohannon, of the existence of the health care plan by letter and told her where she could get information about the plan. Mr. and Ms. Bohannon were clearly aware of the existence of the plan because it paid for extensive cancer treatment received by Mr. Bohannon in 2003. When Ms. Bohannon first asked for information about the HHC plan coverage in December 2003 after coverage was denied, HHC provided the requested information. The rule under these circumstances is that, even if the Bohannons did not have possession of a document explaining the HHC plan coverage until after coverage was denied, they were informed of the existence of the plan and sought to rely on its benefits, so they were charged with knowledge of its contents and limitations. Brown v. Mack Trucks, 111 Ga. App. 164, 166 (141 SE2d 208) (1965); Ga. Farm, &c. Ins. Co. v. Owens, 178 Ga. App. 446, 447 (343 SE2d 699) (1986); Southeastern Security Ins. Co. v. Empire Banking Co., 230 Ga. App. 755, 756-757 (498 SE2d 282) (1998).
Decided February 11, 2005
Reconsideration denied March 10, 2005
Virtually all of the cases applying this long-standing rule deal with contracts of adhesion, whether they be insurance contracts, health care plans, or other contracts drafted and offered without change to employees or the general public. The majority sweeps these cases aside without mentioning them and rules that HHC is estopped from denying clearly excluded coverage because the HHC plan was a contract of adhesion, and HHC did not provide the Bohannons with a copy of the plan showing the specific exclusion until after coverage was denied and they first asked for and received a copy. In support of imposing this new rule on contracts of adhesion, the majority cites to First Financial Ins. Co. v. American Sandblasting Co., 223 Ga. App. 232-233 (477 SE2d 390) (1996). First Financial holds only that coverage ambiguities in contracts of adhesion are construed against the drafter, and therefore the drafter “assumes a duty to define any limitations on that coverage in clear and explicit terms.” Id. This provides no support for the majority’s ruling because the HHC plan unambiguously excluded the coverage sought by Mr. Bohannon. I find no support in Georgia law for the majority’s refusal to enforce the unambiguous provisions of the HHC health care plan.
I am authorized to state that Presiding Judge Blackburn joins in this dissent.
*109Constangy, Brooks & Smith, Jeffery L. Thompson, William J. Martin II, Frank L. Butler III, Drew, Eckl & Farnham, Richard I. Metzger, Morris, Manning & Martin, Lewis E. Hassett, for appellants.
Adams, Jordan & Treadwell, Marc T. Treadwell, for appellee.

 Mr. Bohannon was diagnosed and treated for renal cell carcinoma in 2001 and thereafter followed with periodic CT scans.

 The new 2004 Secure Health drafted plan document was agreed to by HHC and Secure Health on March 2, 2004 with no changes in coverage relevant to the stem cell transplant at issue from the 2003 plan document.

 Contracts of adhesion — those where one party must take or leave terms written and imposed by the other party - are common and legal, hut any ambiguities in the contract are strictly construed against the drafter. Western Pacific Mut. Ins. Co. v. Davies, 267 Ga. App. 675, 681, n. 5 (601 SE2d 363) (2004).