Lifewatch services vs highmark inc

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Justia Opinion Summary LifeWatch is one of the two largest sellers of telemetry monitors, a type of outpatient cardiac monitoring devices used to diagnose and treat heart arrhythmias, which may signal or lead to more serious medical complications. Opinion Annotation. Download PDF. Primary Holding Third Circuit reinstates antitrust allegations against Blue Cross insurers with regard to the denial of coverage for telemetry heart monitors. Enter Your Email.

Justia Legal Resources. Find a Lawyer. Law Students. US Federal Law. US State Law. Other Databases. Daniel E. Laytin , David J. Zott , Kate Guilfoyle , Sarah J. Loney, Jr. Craig A. Hoover , E. This is an antitrust action brought by LifeWatch Services, Inc.

LifeWatch claims Blue Cross violated federal antitrust laws by conspiring to deny coverage of its telemetry monitors. LifeWatch seeks a permanent injunction and treble damages, inter alia.

After almost eight years of litigation, including a stop at the multidistrict litigation panel, litigation before this Court, a substitution of counsel, a visit to the Third Circuit, and a further hearing before this Court on remand, the case comes down to one issue: Does the McCarran-Ferguson Act immunize Blue Cross from antitrust liability under the circumstances of this case?

For the reasons set forth below, the Court concludes that it does. The parties, facts, and procedural history are set forth fully in prior opinions of the Court and the Third Circuit.

See LifeWatch Servs. Highmark Inc. The Court assumes familiarity with the history of this action and sets forth only those facts relevant to the instant Motion to Dismiss. Plaintiff LifeWatch is a large seller of telemetry monitors, one of several types of outpatient cardiac monitors that detect changes in the heart's normal rate or rhythm.

The Association licenses those trade names and trademarks to approximately thirty-six insurance plans and maintains a model medical policy recommending which medical devices to cover, inter alia. The model policy recommends against covering prescriptions for telemetry monitors. The insurers reached this decision despite multiple medical studies concluding that telemetry monitors are effective and, in some cases, superior to other cardiac monitoring devices.

Medicare, Medicaid, and other private insurers cover telemetry monitor prescriptions. LifeWatch refers to this allegedly collusive agreement as the "Uniformity Rule. See Fed. Blue Cross argued: 1 the Complaint failed to allege either an agreement or anticompetitive effects; 2 LifeWatch lacked antitrust standing; and 3 Blue Cross is immune from antitrust liability under the McCarran-Ferguson Act.

Dismiss, ECF No. The Court granted the Motion to Dismiss for failure to allege anticompetitive effects and did not reach the antitrust standing or immunity arguments. LifeWatch , F. The Third Circuit reversed, holding that LifeWatch stated a claim and had antitrust standing.

A party may move to dismiss a complaint for failure to state a claim. When reviewing such a motion, the Court is "required to accept as true all allegations in the complaint and all reasonable inferences that can be drawn from [the allegations] after construing them in the light most favorable to the non-movant. State Police , F. However, "the tenet that a court must accept as true all of the allegations contained in a complaint is inapplicable to legal conclusions. Threadbare recitals of the elements of a cause of action, supported by mere conclusory statements, do not suffice.

Iqbal , U. Twombly , U. Section 1 of the Sherman Act provides that "[e]very contract, combination in the form of trust or otherwise, or conspiracy, in restraint of trade or commerce among the several States, or with foreign nations, is declared to be illegal.

After the Supreme Court found the Sherman Act applicable to the insurance industry, Congress passed the McCarran-Ferguson Act to clarify that regulation of "the business of insurance" should be preserved for the states. See SEC v. Nat'l Sec.

Congress' primary concern with respect to the antitrust exemption was that "cooperative ratemaking efforts be exempt from the antitrust laws" because of "the widespread view that it is very difficult to underwrite risks in an informed and responsible way without intra-industry cooperation. Royal Drug Co. Accordingly, McCarran-Ferguson exempts from the Sherman Act conduct that: 1 "constitutes the business of insurance," 2 is "regulated by state law," and 3 does not "amount to a boycott, coercion, or intimidation.

Pireno , U. A defendant "bears the burden of establishing its immunity from antitrust liability" under McCarran-Ferguson. Lifewatch Servs. The parties concede that Blue Cross' alleged conduct does not amount to a boycott, coercion, or intimidation but disagree about whether the conduct constitutes the business of insurance and whether it is regulated by state law. Two Supreme Court opinions inform this Court's analysis of whether the challenged conduct constitutes the "business of insurance" under the McCarran-Ferguson Act.

The Court concluded that the challenged pharmacy agreements did not constitute the "business of insurance" within the meaning of the McCarran-Ferguson Act because they did not underwrite or spread risk.

Such cost-savings arrangements, the Court concluded, were not the "business of insurance. Congress' clear focus "was on the relationship between the insurance company and the policyholder. In contrast, the pharmacy agreements at issue in Royal Drug were not "between insurer and insured," but were "separate contractual agreements between Blue Shield and pharmacies engaged in the sale and distribution of goods and services other than insurance.

Accordingly, the challenged conduct was not exempt from antitrust laws. The policy limited coverage of chiropractic treatments to "reasonable" charges for "necessary" medical care and services. After receiving chiropractic treatments, a policyholder submitted a claim for reimbursement, and committee members evaluated whether the treatments were necessary and whether the fees were reasonable.

The plaintiff alleged that the insurance company and members of the peer review committee conspired to eliminate price competition among chiropractors in violation of section 1 of the Sherman Act. The defendants claimed immunity under the McCarran-Ferguson Act, arguing their alleged behavior constituted the "business of insurance.

The Court noted that the arrangement between the insurer and the review committee was "logically and temporally unconnected to the transfer of risk accomplished by [the insurer's] policies" because "[t]he transfer of risk from insured to insurer is effected by means of the contract between the parties—the insurance policy—and that transfer is complete at the time that the contract is entered. In distilling the Court's analyses, Pireno identified three criteria relevant to determining whether a particular practice constitutes the business of insurance for the purposes of McCarran-Ferguson immunity: " first , whether the practice has the effect of transferring or spreading a policyholder's risk; second , whether the practice is an integral part of the policy relationship between the insurer and the insured; and third , whether the practice is limited to entities within the insurance industry.

The Court will discuss these criteria seriatim. LifeWatch points to Royal Drug and Pireno to advance its argument that Blue Cross' decision to deny coverage for telemetry monitors does not transfer or spread policyholders' risk. In both Royal Drug and Pireno , the challenged conduct involved post hoc administration of the benefits provided under the contract between the insurer and the insured coverage for prescription drugs and chiropractic treatment, respectively and not the transfer or spread of risk, which had already occurred via the contract.

See Royal Drug , U. In the instant action, the Third Amended Complaint makes this distinction clear. LifeWatch's allegations demonstrate that this case challenges the allocation of risk no telemetry coverage for the insured between the insurer and the insured via the insurance contract:.

According to these allegations, the challenged refusal to cover telemetry monitors occurs "year after year" and "for all patients and all conditions," id. Rather than engaging in a case-by-case, post-issuance review process about whether a specific policyholder's claim involved necessary treatment, as the board in Pireno did, the Defendants in the instant action allegedly formed "a horizontal agreement not to compete based on the package of services offered" in their contracts with insureds.

The contract between insurer and insured allocates risk between the parties. In re Ins. Brokerage Antitrust Litig. In this case, the insurance contract between Blue Cross and its subscribers, by excluding from coverage all telemetry treatment under all circumstances, allocates the risk between the parties.

LifeWatch relies on Pireno to argue that the challenged conduct is not an integral part of the relationship between the insurer and the insured. The Pireno Court determined that the insurers' use of the peer review committee was not an integral part of the policy relationship because "the challenged arrangement between [the insurer] and [the peer review committee] is obviously distinct from [the insurer]'s contracts with its policyholders.

This "separate arrangement between the insurer and third parties not engaged in the business of insurance" rendered the challenged conduct not integral to the policy relationship. In contrast, the challenged conduct in the instant matter involves the package of services offered in Blue Cross' contracts with its subscribers.

In fact, that conduct is integral to the policy relationship. See Ins. Brokerage , F. Blue Cross satisfies the second prong of the business of insurance test. Finally, LifeWatch likens the Blue Cross Blue Shield Association to the Pireno peer review committee to argue that the challenged conduct is not confined to the insurance industry.

But the two organizations have critical differences. Although the Association is not itself an insurer, it owns the rights to Blue Cross and Blue Shield trademark names and licenses those trade names and trademarks to insurance plans.

Further, the Association maintains a model medical policy making coverage recommendations to member plans. These activities render the Association an entity within the insurance industry for the purposes of McCarran-Ferguson. The parties do not dispute that the Defendant plan administrators whose conduct is at issue are entities within the insurance industry. Therefore, the challenged conduct is limited to entities within the insurance industry. Blue Cross satisfies the third prong of the business of insurance test.

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Lifewatch services vs highmark inc	Confirm Password. Justia makes no guarantees or warranties that the annotations are ind or reflect the current state of law, and no annotation is intended to be, nor should it be construed as, legal advice. No-fee downloads of the complaints and baxter crrt machine much more! How can I help you today? Sign up now for free access to this content Enter your details below and select your area s of interest to stay ahead of the curve and receive Zervices daily newsletters.
Cigna hmo customer service	Primary Holding Third Circuit reinstates antitrust allegations against Blue Cross insurers with regard to the denial of coverage for telemetry heart monitors. Parties Stay ahead of the curve In the legal profession, information is the key to success. The Third Circuit reversed the dismissal of the complaint. Password at least 8 characters required. In the legal profession, information is the key to success. Download PDF. Additional or this web page documents may be available in Pacer.
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