Court Opinion

ID: 4960176
Source: CourtListenerOpinion
Date Created: 2021-09-24 14:48:56.31875+00
Date Added: 2024-06-11T08:15:44.258948
License: Public Domain

KLEIN, J.,
Dissenting.
¶ 11 respectfully dissent.8 The majority affirms because it believes that individualized questions about whether certain procedures were “medically necessary” will *377predominate. The overarching question in this case is whether there was a pattern of denials, not medical necessity. And as a practical matter, given the small potential individual damages awards, these claims will never be litigated except as a class action. The trial court ignores the fairness rationale behind class actions. Instead, the trial court allows itself to be lured astray by the insurance companies’ invocation of “medical necessity” and loses sight of the actual focus of the suit — the alleged pattern of denials. The insurance companies want us to believe that a class action is inappropriate because in every case the trial court will have to examine the individual’s diagnosis and determine whether the care was, in the meaning of the contract, “medically necessary.”
¶2 These diversionary tactics are precisely why a class action is necessary. In the case of any individual subscriber patient, the insurer can practically always come up with some justification for the denial. Even the small group of chiropractors here will find it difficult to establish the alleged plot. On the other hand, aggregating the proofs in a class action will cut through the distractions and give the chiropractors their only fair chance at proving their case.
¶ 3 For these reasons, a class action would be the most fair and efficient method of adjudicating the controversies. It would certainly be more efficient than hearing dozens of individual suits. It would be the most fair, because, as I state above, it would be the only realistic way for the chiropractors to present their case.
¶4 This is something of a case of first impression in Pennsylvania and has further significance because the common pleas court, Judge John W. Herron, reached the opposite result than was reached in similar litigation ongoing in federal courts. See In re Managed Care Litigation, 209 F.R.D. 678 (S.D.Fla.2002). Judge Herron’s decision also contradicts controlling precedent. See Sharkus v. Blue Cross of Greater Philadelphia, 494 Pa. 336, 431 A.2d 883 (1981); see also D’Amelio v. Blue Cross of Lehigh Valley, 347 Pa.Super. 441, 500 A.2d 1137 (1985) (“D’Amelio I”).
¶ 5 The federal managed care litigation is an amalgamation of suits by doctors and subscribers from around the country dealing with claims the insurers used a deceptive scheme improperly to deny coverage. The suits are being handled in a coordinated fashion in the Southern District of Florida under the federal Rules of Procedure of the Judicial Panel on Multidistrict Litigation. See 28 U.S.C. 1407 (multidistrict litigation); see also R.P.J.P.M.L. 7.4, 7.5. The federal multidistrict litigation rules are akin to Pennsylvania’s procedure for coordinating suits in different counties. See Pa.R.C.P. 213.1. This particular case has not been removed to federal court.
¶ 6 Nonetheless, the central allegation is the same: the insurers have used a systematic scheme to deny claims improperly. In the federal suit, the district court, Judge Federico A. Moreno, has certified the doctors’ claims for class status, which in light of the broader class of plaintiffs, points out the incorrectness of the trial court’s position.
¶ 7 I will first review the background of this case. I will then explain why I believe, in light of Judge Moreno’s opinion as well as the opinions in Sharkus and DAmelio I, class certification should have been granted.
I. Facts and Procedure
¶ 8 Plaintiffs Steven C. Eisen, D.C., Alice E. Wright, D.C., Douglas G. Pfeiffer, D.C., John Cecchini, D.C. are doctors of chiropractic medicine who have entered *378into contracts with one or more of the defendant insurance companies. The insurance companies operate various health management organizations (“HMOs”). Under the contracts, the chiropractors provide services to the insurance companies’ subscribers for reduced rates. In exchange for the rate reduction, the chiropractors are granted full and complete access to the insurance companies’ subscribers. The contracts provide that for services to be covered, they must be “medically necessary.” “Medically necessary” or “medical necessity” is defined in the chiropractors’ contracts:
The requirement that covered Services or medical supplies are needed, in the opinion of: (a) the Primary Care Physician or the referred specialist, as applicable, consistent with [the HMO’s] polices, coverage requirements and utilization guidelines; and (b) [the HMO], in order to diagnose and/or treat a Member’s illness or injury, as applicable, and:
A. are provided in accordance with accepted standards of American medical practice;
B. are essential to improve the Beneficiary’s net health outcome and may be as beneficial as any established alternatives;
C. are as cost-effective as any established alternative; and
D. are not solely for the beneficiary’s convenience, or the convenience of the Beneficiary’s family or health care Provider.
¶ 9 In their complaint, the chiropractors allege that beginning in 1996, in an effort to reduce costs, the insurance companies changed how they dealt with chiropractic care. The chiropractors assert that in attempting to contain costs, the insurance companies have breached. their contracts with the chiropractors by using eight arbitrary factors to deny coverage:
1. by denying reimbursement for moderately to highly complex problems;
2. by refusing to pay for any chiropractor services other than manipulation;
3. by denying reimbursement for multiple or secondary treatments on the same or subsequent days;
4. by denying reimbursement for chronic conditions;
5. by imposing an artificial cap on the number of times patients may see a chiropractor;
6. by denying all reimbursement once a patient reaches a certain percentage of improvement;
7. by allowing nurses, rather than chiropractors or other qualified caregivers, to deny care; and
8. by relying on undisclosed medical necessity guidelines to deny care for reasons not authorized by the contract.
¶ 10 Alleging the insurance companies breached their contracts by violating the implied covenant of good faith and fair dealing, the chiropractors filed this suit. One year later, they moved for class certification. The motion was assigned to Judge Herron, who held a hearing. At the hearing, the chiropractors presented evidence that the insurance companies were all using the same algorithms, flow charts and treatment codes to deny precertification improperly. (N.T., 4/15/2002, at 19-24; RR. 155a-169a.) Judge Herron explained in an opinion that because he believed the common questions did not predominate over the individual issues, he held that the elements of commonality, typicality, and fairness and efficiency were not present. See Eisen v. Independence Blue Cross, 2002 WL 1803721 (Pa.C.P.Phila.Cty.2002).
*379¶ 11 On appeal, the chiropractors present four questions. The central issue is whether the common questions will predominate over the individual fact questions: 9
1. Whether the trial court abused its discretion in denying appellants’ motion for class certification where appellants’ challenges to the insurance companies’ impediments to paying the chiropractors’ claims demonstrated the requisite commonality, typicality, and fairness and efficiency?
2. Whether the trial court improperly disregarded uncontroverted evidence of the insurance companies’ schemes, which establish predominantly common questions of fact or law?
3. Whether the trial court misapplied Sharkus and D’Amelio I because the procedures in those cases are indistinguishable from the insurance companies’ procedures here?
4. Whether the chiropractors presented sufficient evidence to demonstrate numerosity and adequacy of representation to permit this Court to conclude that Pa.R.C.P. 1702(1) and (4) were satisfied without a remand for an additional hearing?
¶ 12 I agree that class certification should have been granted.
II. Discussion
¶ 13 Although differing somewhat in how they organize the issues, both Pennsylvania and federal law generally require the proponent of the class action to establish the same factors: numerosity of plaintiffs, commonality of issues, typicality of claims/defenses, adequacy of representation, and fairness and efficiency of a class action. Compare Pa.R.C.P. 1702 with F.R.C.P. 23.
1. The chiropractors established commonality by showing some evidence of a scheme to deny claims unfairly.
¶ 14 To satisfy the commonality requirement, the proponent of class certification must show not only a common claim or claims, but also that the common issues predominate over the individual ones. See Pa.R.C.P. 1708(a)(1); see also Weismer by Weismer v. Beech-Nut Nutrition Corp., 615 A.2d 428, 430-31 (Pa.Super.1992).
¶ 15 Judge Herron stated that the common issues do not predominate because recovery on each claim depends on a determination of medical necessity in every case. He distinguished Sharkus, supra, and D Amelio I, supra, stating that those suits dealt with the insurer retroactively changing rules about who pays if the procedure is later declared “medically unnecessary.” For that reason, he saw medical necessity as not being in issue in those cases: “Sharkus and DAmelio I both addressed the fairness of Blue Cross’s retroactive conduct in denying benefits and not the correctness of the medical necessity determination. Here, in contrast, plaintiffs’ claims relate to [the insurance companies’] prospective conduct and not the denial of benefits after treatment was already rendered.” Bisen, 2002 WL 1803721 at *11. In his view, that made “medical necessity” the threshold issue to *380determine if the insurance companies breached the provider agreement.
¶ 16 I disagree with the learned trial court’s analysis. In Sharkus, the proposed class representative plaintiffs all were admitted to Thomas Jefferson University Hospital by a doctor, and after Blue Cross of Greater Philadelphia had paid the bill, it determined that the hospitalization was not medically necessary. As a result, the payment was revoked. Sharkus, 431 A.2d at 884-85. When the hospital sought payment from the subscribers, they instituted a class action against Jefferson and Blue Cross. Id. at 884. The trial court dismissed the class action, and on appeal this Court affirmed. Id.
¶ 17 The Pennsylvania Supreme Court reversed. Although Jefferson Hospital maintained that “individual factual determinations as to medical necessity” were at issue in every case, the Supreme Court saw it differently. 431 A.2d at 887. It explained that the subscribers there did “not seek to prove that plaintiffs hospitalizations were medically necessary.” Id. Rather, they were challenging the procedure for determining whether payment would be made. Id. at 887-88.
¶ 18 This case is no different. The chiropractors do not seek to prove that the treatments were medically necessary. Rather, they are claiming that the insurance companies breached their duty of good faith and fair dealing by denying claims with a set of standards designed to eliminate the more expensive treatments.
¶ 19 For similar reasons, in D’Amelio I we held that “medical necessity” was not in issue. There, Larry D’Amelio was admitted to the hospital for a “depressive reaction.” D’Amelio I, 500 A.2d at 1139. During his stay, the hospital had conducted its own internal review and determined that his hospitalization was medically necessary. Id. After he was discharged, the hospital billed D’Amelio’s insurer, Blue Cross. Blue Cross paid for some of the hospital stay, but denied the rest as “medically unnecessary.” Id. D’Amelio instituted a class action, claiming that the members of the proposed class were being held personally liable to the treating hospitals due to Blue Cross’ retrospective denials. Id. at 1140.
¶ 20 On appeal, we reversed. By way of explanation, we quoted the trial court’s assessment of Sharkus: “[Cjlass certification was appropriate because there was only an ultra vires policy that was being challenged, and not an individual, factual-ized determination.” Id.
¶ 21 I believe these cases require reversal. Judge Herron himself succinctly described our holding in D’Amelio I in a way that shows why his conclusion was incorrect:
[T]he Pennsylvania Superior Court held that class action relief was appropriate to determine the legality of Blue Cross’ retroactive denial of benefits and that medical necessity was not at issue since the action challenged the procedure utilized by Blue Cross in denying benefits after the rendering of treatment and not whether the provider hospital or Blue Cross were medically correct.
Eisen, 2002 WL 1803721 at *11.
¶ 22 That is indistinguishable from this case. I do not see how medical necessity could not be at issue in Sharkus and D’Amelio I and yet be a question here. It was held not in issue there because those cases were about whether subscribers could be liable for hospital bills when the insurance company determined after the fact that the hospitalization was not medically necessary. That is not meaningfully distinguishable from the chiropractors’ claim here that the insurance companies *381here have all used the same systematic scheme to deny claims improperly.
¶ 23 Although both the majority and the trial court see the so-called prospective effect of the denials of precertification as distinguishing this case from D’Amelio and Sharkus, I disagree. In either case — denying services before or after the services are rendered — the claim is that the insurers have a shared scheme to deny the claims. I simply see no distinction. With all due respect, the esteemed majority and the trial court have in effect nullified the holdings of those cases, at least in this appeal.
¶ 24 In addition, Judge Moreno’s certification of a class action in the major federal action points out the error of the trial court decision. In the federal suit, the court is faced with a total of approximately 600,000 doctors from all over the county. With such a large potential class, the number of individual denials of benefits is much greater than in our case. Beyond these factual differences, the doctors in the federal case have also alleged claims based on prompt payment statutes from a large number of states. See In re Managed Care, 209 F.R.D. at 681. This means the district court will be faced with a mind-boggling variety of laws to apply in the individual cases.
¶ 25 Notwithstanding the greater diversity among the individual denials of benefits, Judge Moreno saw no bar to certifying the doctors’ case. He found many common questions, including the medical necessity requirements themselves, the insurers’ use of actuarial guidelines, the use of an automated claims system to adjust codes and reimbursement rates as well as delaying and denying claims automatically. In addition, he saw the issue of whether a conspiracy exists and, if so, its impact as “necessarily a common question which predominates in this action.” In re Managed Care, 209 F.R.D. at 696.
¶ 26 This case shares the same major theme: the insurance companies’ alleged common scheme to deny claims. Here, we are dealing with a much smaller plaintiff class, which indicates a greater commonality of questions. Stated differently, while the common questions are the same, there are many fewer individual questions in this proposed class. Since I agree with the district court that class certification was proper in the federal suit, a fortiori I conclude that it should have been granted in this case.
¶ 27 Of course, one obvious difference is that in the federal suit the plaintiffs have claimed a conspiracy in violation of the federal Racketeer Influenced and Corrupt Organizations Act10 and the Employee Retirement Income Security Act (ERISA).11 Here the only claim is breach of contract. This case can be distinguished by the absence of a direct conspiracy claim. Just the same, it is functionally the same as if the plaintiffs had pled civil conspiracy. Even though they did not specifically plead civil conspiracy, in effect they will be proving one, which I believe makes class certification proper.
2. Realistically, a class action is the only way the chiropractors can present their claims.
¶ 28 There are two ways the chiropractors could prove their allegation of an across-the-board policy to deny claims. They could either produce some sort of a “smoking gun,” such as an internal memo frankly outlining the scheme, or they could establish their claim by inference. If a smoking gun exists, individual chiroprac*382tors are unlikely to be able to find it. In a case against large insurance companies, the chiropractor would have to sift through reams of papers in the hope of finding the proverbial needle in the haystack. The second way to show an arbitrary policy is by statistical analysis, which would potentially prove the policy by inference. To establish a claim by inference, the individual chiropractor would have to acquire documents from non-parties, and then conduct an in-depth study to establish the suspected pattern.
¶ 29 In light of the relatively small potential recovery, the expense of the comprehensive discovery and statistical analysis needed to establish a pattern would effectively preclude litigating the cases individually. A class action, on the other hand, would enable the chiropractors to pursue their claims. This leveling-of-the-field effect is one of the benefits of and reasons for class actions. The Seventh Circuit succinctly stated the principle:
The policy at the very core of the class action mechanism is to overcome the problem that small recoveries do not provide the incentive for any individual to bring a solo action prosecuting his or her rights. A class action solves this problem by aggregating the relatively paltry potential recoveries into something worth someone’s (usually an attorney’s) labor.
Mace v. Van Ru Credit Corp., 109 F.3d 338, 344 (7th Cir.1997); see also Pa.R.C.P. 1708, Explanatory Note; Debbs v. Chrysler Corp., 810 A.2d 137 (Pa.Super.2002); 5A Goodrich-Amram 2d § 1707:1; Uniform Law Commissioners’ Model Class Actions [Act] [Rule], Prefatory Note (“A class action is a procedure by which people with small claims or limited means can exercise their rights and thereby make our system of justice more responsive to their needs.”).
¶ 30 We should bear in mind the equity underpinnings of class actions and equity’s emphasis on fairness. See Uniform Law Commissioners’ Model Class Actions [Act] [Rule], Prefatory Note. These fairness concerns outweigh any question about the individual factors predominating. Although all five factors must be present to certify a class action, if one factor is particularly strong, it can make.up for weakness in another. See Dickler v. Shearson Lehman Hutton, Inc., 408 Pa.Super. 286, 596 A.2d 860, 866 (1991) (court may afford different weight to various factors). Therefore, in this case any question about whether the common questions predominate is overcome by the fairness and efficiency of a class action.
3. The claims and defenses are sufficiently typical because they arise out of the same basic scenario.
¶ 31 I conclude that the claims and defenses are sufficiently typical for largely the same reasons I believe the commonality requirement is met. That is, the real issue is whether the insurance companies methodically and arbitrarily denied claims. That is what the chiropractors will be trying to prove, and the insurance companies, disprove. Because both the claims and defenses will arise from the same factual and legal predicate, typicality has been established. See D’Amelio I, 500 A.2d at 1146; see also In re Managed Care, 209 F.R.D. at 695 (“Because the Provider Plaintiffs have demonstrated a common scheme or course of conduct, they also have shown typicality.”).
III. Conclusion
¶ 32 This case is not about individual denials of benefits. Rather, it is about the chiropractors’ allegations that the insurance companies systematically denied the most expensive claims. Because I do not *383agree that the trial court properly denied class certification, I would reverse.

. For simplicity, I will refer to plaintiffs Steven C. Eisen, D.C., Alice E. Wright, D.C., and Douglas G. Pfeiffer, D.C., and John Cecchini, D.C. collectively as "the chiropractors.” Defendants Independence Blue Cross, Ameri-Health Administrators, Inc., Keystone Health Plan East, Inc., QCC Insurance Company and AmeriHealth Insurance Company will be called collectively "the insurance companies.”

. Judge Herron, too, acknowledged that predominance was the central issue:
Specifically, the Court is unconvinced that the Complaint presents sufficient questions of fact that are common to the class, that the claims and applicable defenses will be typical throughout the class and that a class action is a fair and efficient method to address the plaintiffs’ grievances where the common questions do not predominate over individual issues.
2002 WL 1803721 at *8.

. 18 U.S.C. § 1961-1968.

. 29 U.S.C.A. § 1001 etseg.