(Los Angeles, CA – Insurance News 360) – A decade of legal battles over the implementation of the Unfair Insurance Practices Act (UIPA), the California Supreme Court denied review of the 4th Appellate District’s decision that upheld Commissioner Dave Jones’ Fair Claims Settlement Practices Regulations. The regulations detail how insurance claims must be processed, and are the foundation of determining how many violations occur as part of the fine assessment process.
This allows the Department of Insurance to levy up to $91 million in fines against PacifiCare for numerous unfair claims practices, including wrongful denials for life-saving treatment for people battling serious illness and claim payment denials for providers and hospitals—all because the insurer was focused on maximizing profits through what it called “efficiencies” after the 2005 botched $9 billion acquisition of PacifiCare by UnitedHealthcare. Examinations revealed that the company knew about these issues.
Misrepresenting what medications or treatments an insurance policy covers, failing to promptly pay claims where liability is reasonably clear, and forcing claimants to file lawsuits to get full payment, and other acts are considered unfair practices. The Insurance Code allows the commissioner to impose fines of up to $5,000 each time an insurer commits an unfair act or practice on a consumer, or up to $10,000 each time if the insurer did so willfully.
“UnitedHealthcare purchased PacifiCare and imposed cost-cutting measures that destroyed PacifiCare’s claims-handling processes and its arguments in litigation that insurance companies should be allowed to willfully harm consumers as long as they don’t do it too often, reflect a gross disregard of the lives and well-being of the consumers who paid for the promise of coverage,” Commissioner Jones said. “Customers have no choice but to rely on the integrity of their health insurance companies. PacifiCare breached that trust. By any measure, 908,000 violations reflect a general business practice of violating consumer protection laws. I am delighted the Supreme Court has rejected further challenges to the insurance commissioner’s authority to punish insurance companies for knowingly harming even one consumer.”
Based on departmental examination results and following an administrative hearing that took three years, Insurance Commissioner Dave Jones found PacifiCare committed 908,547 separate violations of the UIPA, and he imposed fines aggregating $173,603,750 in penalties. On behalf of PacifiCare, UnitedHealthcare sued the commissioner, arguing that none of its harmful conduct violated the Insurance Code.
The Appeals Court rejected PacifiCare’s argument that insurers are immune from fines for unfair acts, stating “PacifiCare’s interpretation of section 790.03(h) is not only internally problematic, it stands in contrast to virtually every other statute the Legislature has enacted in connection with (1) enforcement of the Insurance Code against insurers generally; (2) enforcement of the UIPA in particular; and (3) the imposition of administrative penalties against insurers in other contexts.”
The court also rejected PacifiCare’s argument that the commissioner must prove an insurer had “actual knowledge” of its illegal conduct and held that it was within the commissioner’s authority to hold the insurer responsible if its agents or employees were aware of facts that would cause a reasonable person to know of the violations. The court also found the commissioner’s reasoning was sensible in that restricting the definition of “knowingly” to one particular individual’s actual knowledge would fail to take into account that many people handle a claim, and an unfair practice can be committed by cumulative acts, not simply the intentional act of one person.”
Source: California Insurance Department.