Ciamaichelo v. Independence Blue Cross
Ciamaichelo v. Independence Blue Cross
Opinion of the Court
OPINION
Appellants Jules Ciamaichelo and Rob Stevens, Inc. commenced a class action against Appellee Independence Blue Cross (“IBC”) in the Court of Common Pleas of Bucks County on behalf of themselves and other IBC subscribers, policyholders and members. In their Class Action Complaint (“Complaint”), Appellants alleged that IBC violated the Nonprofit Corporation Law of 1988 (“Non-Profit Law”), 15 Pa.C.S. § 5101 et seq., and breached contractual and fiduciary duties in having amassed an excess in surplus funds for purposes inconsistent with its non-profit status. We granted review to consider whether the Commonwealth Court correctly determined that the Complaint could not proceed in the court of common pleas due to a lack of subject matter jurisdiction and the filed-rate doctrine. For the following reasons, we conclude that the Commonwealth Court erred. Accordingly, the order of the Commonwealth Court is reversed, and this case is remanded to the Commonwealth Court for further proceedings.
Appellants commenced this action on August 21, 2001. Appellants’ Complaint alleges in relevant part that: IBC is a non-profit hospital corporation governed by the Non-Profit Law and has a corporate mandate to be a health care insurer of last resort; that IBC “accumulated excess funds (called ‘surplus’ or ‘reserves and unassigned funds’) of at least $349 million and perhaps as much as $438 million”; that “surplus is the amount that remains when an insurer subtracts its liabilities from its assets” and constitutes funds “not necessary for the ongoing operations of an insurer but rather constitutes
In Count 1, the Complaint claims that IBC violated Section 5545 of the Non-Profit Law, 15 Pa.C.S. § 5545,
By way of relief, the Complaint requests that the court authorize the class action; declare that IBC violated the NonProfit Law by accumulating the exeess surplus and engaging in for-profit activities; order such relief under the Non-Profit Law as it may deem appropriate with regard to the disposition of the excess surplus and in general; award them reasonable attorneys’ fees from the excess surplus; require that IBC specifically perform the requirements of the Non-Profit Law; order an accounting and impose a constructive trust over the excess surplus; and order that IBC produce documents that fall within thirteen categories.
On October 22, 2001, IBC filed preliminary objections to the Complaint. In one preliminary objection, IBC asserted that since Counts I, II, and III essentially challenge IBC’s rates and reserves, the Counts must be dismissed for lack of subject matter jurisdiction because under the insurance statutes, such matters are committed to the exclusive jurisdiction of the Pennsylvania Department of Insurance (“Department”). In a second preliminary objection in the nature of a demurrer, IBC asserted that since Counts I, II, and III essentially challenge rates that were reviewed and approved as reasonable and nondiscriminatory by the Department, the Counts are barred under the filed-rate doctrine. See Montana-Dakota, Utilities Co. v. Northwestern Public Service Co., 341 U.S. 246, 251, 71 S.Ct. 692, 95 L.Ed. 912 (1951) (holding that the right to a reasonable utility rate is the right to the rate that the Federal Power Commission files or fixes, and that, except for review of the Commission’s orders, the courts can assume no right to a different rate on the ground that it is the only or the more reasonable one). In a third preliminary objection, IBC asserted that Counts I and IV must be dismissed because Appellants are not among the persons upon whom the Non-Profit
By order dated June 13, 2001, the trial court overruled IBC’s preliminary objections. The trial court’s decision was premised on the principle that preliminary objections should be sustained and a complaint dismissed only in cases that are clear and free from doubt. See, e.g., Schott v. Westinghouse Elec. Corp., 436 Pa. 279, 259 A.2d 443, 449 (1969). On July 1, 2002, IBC moved for reconsideration of the trial court’s June 13, 2001 order or alternatively, to vacate the order. On July 15, 2002, IBC filed an Application to Amend Interlocutory Order to Include Statement Specified in 42 Pa.C.S. § 702(b) and for a Stay of all Proceedings. On July 19, 2002, the trial court entered an order denying IBC’s Motions and Application.
On August 19, 2002, IBC filed a Petition for Review in the Commonwealth Court, seeking review of the trial court’s denial of certification under 42 Pa.C.S. § 702(b) and leave to appeal the trial court’s June 13, 2001 interlocutory order. See Pa.R.A.P. 1311, 1513. IBC presented three substantive issues for review in its Petition: (1) whether Appellants’ Complaint must be dismissed for lack of subject matter jurisdiction because the Legislature has given the Department exclusive
On December 20, 2002, the Commonwealth Court en banc issued a published opinion and order. Ciamaichelo v. Independence Blue Cross, 814 A.2d 800 (Pa.Cmwlth. 2002). On the question of jurisdiction, the Commonwealth Court agreed with IBC. Concluding that Appellants’ claims were in actuality challenges to the level of IBC’s rates and reserves and that Appellants did not request any relief that the court of common pleas was authorized to order, the court held that only the Department has the jurisdiction to resolve Appellants’ claims. Id. at 802 (citing 40 P.S. §§ 71, 6123, 6124(a), 6125 and 31 Pa.Code §§ 84a.1-84a.8). Alternatively, the Commonwealth Court also agreed with IBC on application of the filed-rate doctrine. Describing the doctrine as a rule that preserves the exclusive role of a regulatory agency in approving rates, and focusing on the interaction between the rates an insurer charges and the reserves it accumulates, the court determined that the doctrine barred Appellants’ claims because a decision from the trial court that IBC was holding excessive reserves would necessarily require a recalculation of rates that the Department had approved. 814 A.2d at 804-05. Accordingly, the Commonwealth Court reversed the trial court’s order overruling IBC’s preliminary objections and dismissed the Complaint.
Appellants filed a Petition for Allowance of Appeal, which this Court granted. Ciamaichelo v. Independence Blue Cross, 574 Pa. 749, 829 A.2d 1158 (2003).
Turning to the competing positions the parties presently set forth for our consideration in applying this legal framework, Appellants contend that the Commonwealth Court made two errors. First, the court mischaracterized the allegations
We agree with Appellants. At his juncture in the proceedings, on preliminary objections, we do not conclude that it is clear and free from doubt that Appellants’ Complaint amounts to nothing more than a request that the court of common pleas second-guess an approved rate, as IBC argues, or that the court assume the Department’s regulation of IBC’s reserves or risk-based capital. See Hospital Healthsystem Ass’n of Pennsylvania, 888 A.2d at 607. Rather, we view the Complaint as raising whether IBC violated the Non-Profit Law and committed breaches of contractual and fiduciary duties in amassing a fund designated as surplus that was in amount, over and above that necessary for IBC to operate properly, meet its legal obligations, or secure its financial solvency, and in dedicating that fund to certain purposes. These are claims that the Legislature has empowered the court of common pleas, not the Department, to adjudicate. See 15 P.S. §§ 5508, 5791-5793; 42 Pa.C.S. § 931.
In this regard, we find guidance in one of our recent decisions. In Drain v. Covenant Insurance Company, 551 Pa. 570, 712 A.2d 273 (1998), Covenant Life Insurance Company (“Covenant” or “Company”) sought and received the Depart
Likewise, even though the Complaint in this case refers to IBC’s surplus, we conclude that Appellants’ action was properly brought in the court of common pleas inasmuch as the claims asserted therein concern violations of the Non-Profit Law and breaches of common law duties, which are claims that the Legislature has committed to that court’s jurisdiction. See 15 P.S. §§ 5508, 5791-5793; 42 Pa.C.S. § 931. Therefore, we hold that the Commonwealth Court erred in sustaining IBC’s preliminary objections for lack of subject matter jurisdiction, and that Appellants’ challenge to IBC should proceed in the way Appellants commenced it, as a civil action in the court of common pleas.
It is our additional view that in this action, the doctrine of primary jurisdiction that this Court articulated in Elkin v. Bell Telephone Company of Pennsylvania, 491 Pa. 123, 420 A.2d 371 (1980), controls. As Elkin teaches, the doctrine of primary jurisdiction is concerned with promoting proper relationships between the courts and administrative agencies charged with particular regulatory duties. Id. at 376. Primary jurisdiction applies where a claim is originally cognizable in the courts, and comes into play whenever enforcement of the claim requires the resolution of issues which, under a regulatory scheme, have been placed within the jurisdiction of an administrative body; in such a case the judicial process is suspended pending referral of such issues to the administrative body for its views. Id.
In light of the Department’s authority to oversee IBC’s financial condition and approve or monitor many of IBC’s operations, see supra p. 8, and the trial court’s subject matter jurisdiction, see id., we conclude that instead of placing this case in the exclusive domain of either the Department or that of the trial court, the proper course is to allow the trial court to refer to the Department any issue or matter that is revealed to lie within the Department’s regulatory jurisdiction, including any remedial action should that become necessary, and is of sufficient complexity to require the Department’s special competence. See id. at 377.
Therefore, for all of the foregoing reasons, the order of the Commonwealth Court is reversed, and this case is remanded to the Commonwealth Court with instructions to resolve the outstanding issue raised by IBC in its Petition for Review filed in the Commonwealth Court.
This matter was reassigned to this author.
. We observe that in the insurance industry, the term “surplus” is used interchangeably with the term “reserves.” Appellants’ Complaint uses the term "surplus” to refer to funds that an insurer accumulates to cover future exigencies and is unassigned to any particular claim. It is not to be confused with funds that an insurer dedicates to covering claims that are incurred, but not paid. See 41 P.S. § 71.
. Section 5545 of the Non-Profit Law states:
§ 5545. Income from corporate activities
A nonprofit corporation whose lawful activities involve among other things the charging of fees or prices for its services or products, shall have the right to receive such income and, in so doing, may make an incidental profit. All such incidental profits shall be applied to the maintenance and operation of the lawful activities of the corporation, and in no case shall be divided or distributed in any manner whatsoever among the members, directors, or officers of the corporation. As used in this section the terms fees or prices do not include rates of contribution, fees or dues levied under an insurance certificate issued by a fraternal benefit society, so long as the distribution of profits arising from said fees or prices is limited to the purposes set forth in this section and section 5551 (relating to dividends prohibited; compensation and certain payments authorized).
15 Pa.C.S. § 5545.
. Section 5551 (c) of the Non-Profit Law provides:
§ 5551. Dividends prohibited; compensation and certain payments authorized
(c) Certain payments authorized. — A nonprofit corporation may confer benefits upon members or nonmembers in conformity with its*420 purposes, may repay capital contributions, and may redeem its subvention certificates or evidences of indebtedness, as authorized by this article, except when the corporation is currently insolvent or would thereby be made insolvent or rendered unable to carry on its corporate purposes, or when the fair value of the assets of the corporation remaining after such conferring of benefits, payment or redemption would be insufficient to meet its liabilities. A nonprofit corporation may make distributions of cash or property to members upon dissolution or final liquidation as permitted by this article.
15 Pa.C.S. § 5551(c).
. In relevant part, sections 5508 and 5793 state, respectively:
§ 5508. Corporate records; inspection by members
(b) Right of inspection by a member. — Every member shall, upon written verified demand stating the purpose thereof, have a right to examine, in person or by agent or attorney, during the usual hours for business for any proper purpose, the membership register, books and records of account, and records of the proceedings of the members, directors and any other body, and to make copies or extracts therefrom. A proper purpose shall mean a purpose reasonably related to the interest of the person as a member....
§ 5793. Review of contested corporate action
(a) General rule. — Upon petition of any person whose status as, or whose rights or duties as, a member, director, member of an other body, officer or otherwise of a nonprofit corporation are or may be affected by any corporate action, the court may hear and determine the validity of such corporate action.
(b) Powers and procedures. — The court may make such orders in any such case as may be just and proper, with power to enforce the production of any books, papers and records of the corporation and other relevant evidence which may relate to the issue. The court shall provide for notice of the pendency of the proceedings under this section to all persons affected thereby. If it is determined that no valid corporate action has been taken, the court may order a meeting*421 to be held in accordance with section 5792 (relating to proceedings prior to corporate action).
15 Pa.C.S. §§ 5508(b); 5793(a)-(b).
. In its Commonwealth Court appeal, IBC sought review of the trial court's denial of these particular preliminary objections. IBC raised additional preliminary objections, which were denied by the trial court, but not included in IBC's Commonwealth Court appeal. The additional preliminary objections IBC raised were: whether Counts I, II, and III should be dismissed for Appellants’ failure to exhaust the administrative remedies available to them in the Department itself to contest IBC's rates or reserves; whether Counts I, II, and III should be dismissed under Pa.R.C.P. No. 1028(A)(5) for failure to join the Department, which is a necessary and an indispensable party; whether Count II should be dismissed because Appellants did not comply with Pa.R.C.P. No. 1028(A)(2) and attach a copy of the written agreement that IBC allegedly breached; and whether Counts II and III should be dismissed for failure to state a claim for breach of contract and breach of fiduciary duty, respectively.
. Apparently, in light of its disposition of the first two issues IBC raised in its appeal, the Commonwealth Court did not address the third issue that IBC raised, namely, Appellants' standing and right to relief under the Non-Profit Law.
. Our standard and scope of review is well-settled. In ruling on whether the preliminary objections IBC filed were properly sustained, we must determine whether it is clear and free from doubt from all the facts pleaded that Appellants will be unable to prove facts legally
On preliminary objections, all material facts set forth in the complaint as well as all inferences reasonably deducible therefrom are admitted as true for the purpose of review. Employers Ins. of Wausau v. Com., Dept. of Transp., 581 Pa. 381, 865 A.2d 825, 830 n. 5 (2005).
. In light of our view of the Complaint, we do not address whether the filed-rate doctrine would have applied in this context.
Dissenting Opinion
dissenting.
The majority frames the issues raised by the Complaint in a broad fashion, see Majority Slip Op., at 9, but in the end, these issues are resolved by determining whether IBC’s surplus is excessive. Although appellants allege IBC violated the nonprofit corporation law, breached its fiduciary duties, and breached its contract, these claims necessarily involve resolution of proper setting of rates and reserves. The setting of rates and reserves is within the Insurance Department and its Commissioner’s province and expertise. 40 Pa.C.S. § 6124(a).
The practical question before this Court is who should make that determination, for both trial court and Insurance Department have authority to do so
The appellants bypassed the Department’s area of expertise by asking the courts to determine whether their insurance provider is holding excess reserves and surpluses
Therefore, I would affirm the Commonwealth Court’s grant of preliminary objections.
. A person complaining of anything done or omitted to be done by a person subject to the jurisdiction of an agency, in violation of a statute or regulation administered or issued by the agency may file a complaint with the agency. If the complaint relates to a provision in a tariff, policy form or other similar contract document on file with the agency,
1 Pa.Code § 35.9.
. Since the initiation of this suit, IBC and the other Pennsylvania Blue Insurance Plans sought approval of their reserves and surpluses by the Insurance Commissioner. The Commissioner issued a determination and order February 9, 2005, which laid out the range of acceptable surplus levels and ordered for the 2003 calendar year IBC’s surplus level was "efficient.” Insurance Department Order, Re: Applications of Capital Blue Cross, et al., Misc. Docket No. MS05-02-006, at 1.
Additionally, appellants filed a complaint in the Insurance Department requesting the Insurance Commissioner make a determination that IBC’s surpluses and reserves are excessive and order appropriate relief. The Insurance Commissioner issued an order dismissing the complaint because appellants did not utilize the proper vehicle to raise their challenge; a class action complaint was not the proper vehicle. Order of Insurance Commissioner, Docket No. FC03-01-036, filed June 17, 2004.
Reference
- Full Case Name
- Jules CIAMAICHELO and Rob Stevens, Inc., Appellants, v. INDEPENDENCE BLUE CROSS, Appellee
- Cited By
- 31 cases
- Status
- Published