Final Judgment by Consent Between Commonwealth of Massachusetts and The MEGA Life and Health Insurance Company, Mid-West National Life Insurance Company of Tennessee, and HealthMarkets, Inc.
This agreement resolves a lawsuit brought by the Commonwealth of Massachusetts against The MEGA Life and Health Insurance Company, Mid-West National Life Insurance Company of Tennessee, and HealthMarkets, Inc. The companies agree to stop selling and renewing certain health benefit plans in Massachusetts for five years, notify policyholders about their rights and plan details, and comply with specific restrictions on marketing and claims practices. The agreement aims to protect consumers and ensure compliance with state insurance laws, while avoiding further litigation. The companies deny any wrongdoing.
SUFFOLK, SS. | SUPERIOR COURT DEPARTMENT CIVIL ACTION NO. 06-4411-F |
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COMMONWEALTH OF MASSACHUSETTS, | ) | |||
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Plaintiff, | ) | |||
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v. | ) | |||
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THE MEGA LIFE AND HEALTH INSURANCE | ) | |||
COMPANY, MID-WEST NATIONAL LIFE | ) | |||
INSURANCE COMPANY OF TENNESSEE | ) | |||
and HEALTHMARKETS, INC., | ) | |||
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Defendants. | ) | |||
) |
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(a) | representing as a Health Benefit Plan benefit that prospective purchasers cannot be singled out for a rate increase or cancellation; |
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(b) | representing that Defendants products provide prescription drug coverage if they do not; | ||
(c) | requiring association group membership in connection with the marketing and sale of any Health Benefit Plan under M.G.L. c. 176J for individuals or small employer groups of five (5) or fewer employees unless the association operates as an intermediary in accordance with M.G.L. c. 176J; | ||
(d) | requiring association group membership in connection with their sale of any Health Benefit Plan under M.G.L. c. 176J to small employer groups of six (6) or more employees; | ||
(e) | declining to pay claims that are valid and outstanding (for purposes of Sections 2 (e) and (g), the Attorney General and the Defendants agree and acknowledge that claims are outstanding so long as they are open or subject to grievances or external appeals on or after entry of this Final Judgment by Consent) for coverages and benefits mandated by M. G. L. c. 175, § 47C (newborn wellness); M. G. L. c. 175, §47F (maternity care); M. G. L. c. 175, § 47G (cytologic screening and mammographic examinations); M. G. L. c. 175, § 47H (infertility treatment); and M. G. L. c. 175, § 47W (contraceptive services) when it knows or should know that such denial(s) violate these mandated benefit laws in Massachusetts; | ||
(f) | disclosing protected health information, as that term is defined by 45 C.F.R. § 164.501, to any third party in any manner that MEGA or Mid-West know or should know violates the privacy provisions of HIPAA (45 C.F.R. Parts 160 and |
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164) and M. G. L. c. 175I and c. 214, § 1B in connection with their conduct of health insurance business operations in Massachusetts; |
(g) | declining to pay claims that are valid and outstanding in violation of the provisions of M. G. L. c. 176J, §§ 1, 2 and 5, and c. 176N, § 2, when it knows or should know that such denial(s) violate these laws in Massachusetts; | ||
(h) | using any advertisement in Massachusetts that contains the representations any doctor or choose any doctor anytime, anywhere or equivalent language, unless such advertisements clearly and conspicuously, and in close proximity to the representation, disclose any exceptions, restrictions and/or limitations that apply; | ||
(i) | using any advertisement in Massachusetts that it knows or should know is false or deceptive, including, but not limited to, any representation offering prescription drug coverage, except where the product being offered provides insured prescription benefits; | ||
(j) | using in Massachusetts any advertisements or proposed agent scripts that unfairly or incompletely compare any MEGA or Mid-West product to any Health Benefit Plan offered by a competitor, or otherwise make comparisons that it knows or should know are false, incomplete or unfair; | ||
(k) | offering and issuing health insurance policies to Medicare-eligible residents that fail to comply with M. G. L. c. 176K or 42 USC § 1396, et seq. |
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(a) | Implement the revised training materials for their agents licensed to sell insurance Health Benefit Plans in Massachusetts that incorporate Section 1, entitled Health Insurance Agent Training, of the performance standards contained in the MultiState Regulatory Settlement Agreement entered into by the Defendants MEGA and Mid-West as of May 29, 2008 (the MultiState RSA); | ||
(b) | Implement the revised agent oversight procedures that incorporate Section 2, entitled Agent Oversight, of the performance standards contained in the MultiState RSA; | ||
(c) | Submit to the Commonwealth, on or before February 14, 2010, a copy of the report required by Section G.3. of the MultiState RSA and concerning the status of and compliance with MultiState RSA performance standards; | ||
(d) | Notwithstanding the foregoing, the Defendants shall be subject to the requirements of this Section 4 only if they, jointly or severally, are acting as a sales agency and selling the Health Benefit Plans of a third party carrier. |
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(a) | Consumer Relief funds will be distributed to Affected Consumers who: |
i) file a claim after the entry of this Judgment through a claims reassessment process as may be required by a regulatory Settlement Agreement between the Defendants and the DOI; | |||
ii) filed a consumer complaint with the Commonwealth prior to August 1, 2009; or | |||
iii) file a claim through a claims reassessment or complaint review process as may defined by the Attorney General, at her sole discretion, to provide relief for otherwise unremediated losses to Massachusetts consumers who: (1) before or during the period of coverage reached the age of Medicare eligibility, (2) had claims denied because of policy maximums on benefits or |
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the number of services within a period of time, (3) had claims denied because of coverage limits on prescription drugs, doctors office visits, simultaneous surgeries, or procedures related to pregnancy, (4) terminated coverage citing a miscommunication at presentation or similar complaint of agent misconduct; or (5) the Office of the Attorney General determines suffered ascertainable loss or other cognizable harm as a result of Defendants conduct. |
(b) | The Attorney General, in the exercise of reasonable discretion, will endeavor to retain a qualified, independent, professional third-party administrator to administer, and process payments resulting from, the Consumer Relief Program described in this Section 5 (Settlement Administrator). The Defendants shall cooperate with the Attorney General and the Settlement Administrator, if any, to efficiently and effectively complete the Consumer Relief Program. The Defendants shall, at their own cost and expense (separate and apart from any payment made to the Commonwealth under this Judgment), provide information within a reasonable period of time in response to any reasonable requests from the Attorney General or Settlement Administrator for information or data to be used to establish and complete the Consumer Relief Program, which information or data may include, without limit, claims and premium payment data by consumer. The Attorney General and the Defendants agree and acknowledge that any requests for information or data under this Section shall be reasonable so long as they can be addressed by the Defendants in the ordinary course of business, during ordinary business hours, employing existing systems and resources and using existing staff. The Attorney General further agrees and acknowledges that |
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any information or data produced by the Defendants under this Section 5 may contain highly sensitive and commercially valuable confidential information as well as highly sensitive and private health information. The Attorney General therefore agrees that to the extent permissible under law, she will maintain the confidentiality of any information or data produced by the Defendants pursuant to this Section 5; she will notify the Defendants in writing within seven (7) days of any request or court order seeking the production of such information or data; and upon the conclusion of the Consumer Relief Program, she will either return all such information or data to the Defendants or certify in writing that she has destroyed the same. The Attorney General further agrees that if she retains a Settlement Administrator, she will obtain the Settlement Administrators agreement to abide by the terms and conditions for maintaining the confidentiality of Defendants information or data described in this Section 5 (b). The direct costs of the Attorney Generals Office and any Settlement Administrator in administering, and making payments to consumers resulting from, the Consumer Relief Program shall be paid or reimbursed from the Consumer Relief fund. If the Attorney General is unable to secure the services of a Settlement Administrator upon terms and conditions that the Attorney General determines to be reasonable and acceptable in her sole discretion, the Defendants shall provide any administrative services determined by the Attorney General to be reasonably necessary to implement and complete the Consumer Relief Program, and the direct costs of the Defendants, including such costs as may be reasonably necessary to expand the Defendants capacity and/or capabilities, in |
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administering, and making payments to consumers resulting from, the Consumer Relief Program shall be paid or reimbursed exclusively from the Consumer Relief fund, provided, however, that such direct costs must be previously approved by the Attorney General. |
(c) | The Attorney General shall report to the Defendants the names of the consumers who receive Consumer Relief funds and the amounts each received on a semiannual basis beginning on March 1, 2010. The Attorney General shall also notify the Defendants in writing thirty (30) days after the completion of the Consumer Relief Program, said notice to include the amount of the funds, if any, that remain unexpended. If, after the Attorney General completes the Consumer Relief Program described in this Consent Judgment, Consumer Relief funds remain unexpended, under this Consent Judgment the Attorney General shall direct any residue to the Local Consumer Aid Fund, established pursuant to M.G.L. c. 12, § 11G. | ||
(d) | The Attorney General acknowledges that the Defendants MEGA and Mid-West have agreed to make certain payments pursuant to a certain Regulatory Settlement Agreement dated August 26, 2009, including the sum of two million dollars ($2,000,000) to the DOI and an as yet undetermined sum pursuant to a claims reassessment process (DOI Process). Relative to these payments, the Parties agree as follows: (i) The Attorney General shall credit the two million dollars ($2,000,000) payment to the penalty payments due from the Defendants MEGA and Mid-West under this Section 5. Upon written certification by the Defendants MEGA and Mid-West that the two million dollars ($2,000,000) payment due the |
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DOI has been made, the Attorney General shall deem the penalty payment due under this Section 5 from Defendants MEGA and Mid-West (but not Defendant HealthMarkets) to be fully satisfied. (ii) The Parties agree that the amount to be paid to consumers under the DOI Process is presently unknowable and uncertain. As a result, the Attorney General shall preliminarily credit the Consumer Relief payment due from each of the Defendants MEGA and Mid-West by two hundred thousand dollars ($200,000) (for a total credit of four hundred thousand dollars ($400,000)) on account of the sum due each for the DOI Process. Within thirty (30) days of the completion of the DOI Process as determined by the DOI, the Defendants MEGA and Mid-West shall submit to the Office of the Attorney General a written statement signed by an authorized representative attesting to the total amount of payments to consumers made pursuant to the DOI Process (Claims Reassessment Statement). From the date of entry of this Final Judgment by Consent until such time as the Defendants deliver the Claims Reassessment Statement, the Defendants shall submit to the Office of the Attorney General every ninety (90) days a quarterly statement signed by an authorized representative describing (i) the total amount of payments to consumers made during that period through the DOI Process, and (ii) the then current estimate on the amount of time and additional payments needed to complete the DOI Process. The Attorney General and the Defendants agree and acknowledge that said quarterly statement is not intended and shall not constitute a statement of material fact; and such statement is not intended to and shall not constitute a representation or warranty by the Defendants of the information |
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contained therein. If the total amount of such claim reassessment payments is less than four hundred thousand dollars ($400,000), the Defendants MEGA and Mid-West shall, concurrent with the submission of the Claims Reassessment Statement, deliver to the Office of the Attorney General a check or checks for the difference between the total credit amount of four hundred thousand dollars ($400,000) and the amount paid. If the total amount of such claim reassessment payments is more than the total credit amount of four hundred thousand dollars ($400,000), the Office of the Attorney General shall, within thirty (30) days of receipt of the Claims Reassessment Statement, deliver to each of the Defendants MEGA and Mid-West a check for one-half of the total amount by which such payments exceeded the total credit amount of four hundred thousand dollars ($400,000), but not to exceed a maximum reimbursement to MEGA and Mid-West of six hundred thousand dollars ($600,000) (collectively, or three hundred thousand dollars ($300,000) to each of MEGA and Mid-West) regardless of the amount by which claims reassessment payments exceed the total credit amount of four hundred thousand dollars ($400,000). To provide for this potential payment following the claims reassessment process, the Office of the Attorney General may maintain six hundred thousand dollars ($600,000) of the Consumer Relief Funds in a separate escrow account until the claims reassessment process is complete. Nothing in this Judgment prohibits the Attorney General, the DOI and the Defendants from agreeing to administer the DOI Process as part of the Consumer Relief Program required by this Section. |
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(a) | the steps that Defendants have performed since February 1, 2007, to reassess and remediate categories of claims originally denied, in whole or in part, that should have been paid as valid claims in accordance with: |
1. | benefits mandated by M. G. L. c. 175, § 47C (newborn wellness); M. G. L. c. 175, §47F (maternity care); M. G. L. c. 175, § 47G (cytologic screening and mammographic examinations); M. G. L. c. 175, § 47H (infertility treatment); and M. G. L. c. 175, § 47W (contraceptive services) (collectively Mandated Benefits); | ||
2. | policy exclusion limitations mandated by M. G. L. c. 176J, §§ 1, 2 and 5, and c. 176N, § 2 (Exclusion Limitations); or | ||
3. | the claims reassessment process required by a certain Regulatory Settlement Agreement, as amended, between the DOI and the Defendants MEGA and Mid-West and dated December 6, 2006. |
(b) | the total number of consumers who have had claims paid through said claims reassessment processes, and the total amount of payments made by Defendants since February 1, 2007 up to and including the date of entry of this Final Judgment by Consent to remediate claims described in Subsection (a) of this Section 6. If the total amount of such claim remediation payments, plus interest, made by the Defendants since February 1, 2007 up to and including the date of |
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entry of this Final Judgment by Consent is less than two million one hundred and seventy five thousand six hundred and sixty two dollars ($2,175,662), the Defendants shall collectively, and separate and apart from the payments required by Section 5 above, deliver to the Commonwealth within one-hundred and eighty (180) days of entry of this Final Judgment by Consent a check for the difference between two million one hundred and seventy five thousand six hundred and sixty two dollars ($2,175,662) and the amount of such claim remediation payments. Any such payment shall be made to the Local Consumer Aid Fund, as established by M.G.L. c. 12, § 11G, and shall be made by check made payable to The Commonwealth of Massachusetts, Local Consumer Aid Fund delivered to Thomas OBrien, Assistant Attorney General, at the Office of the Attorney General, Health Care Division, One Ashburton Place, Boston, Massachusetts 02108. |
(c) | The Attorney General agrees that to the extent permissible under law, she will maintain the confidentiality of any individually identifiable health information that may be contained in the written statement or any portion of its contents produced by the Defendants pursuant to this Section 6; she will notify the Defendants in writing within seven (7) days of any request or court order seeking the production of individually identifiable health information that may be contained in the written statement. | ||
(d) | Nothing in this Section 6 is intended to create nor does it create any obligation on the part of the Defendants to reassess or remediate any claim. |
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Commonwealth of Massachusetts | Defendants | |
Thomas M. OBrien, Esq. Assistant Attorney General Office of the Attorney General One Ashburton Place Boston, MA 02108 Thomas.M.O ***@*** | Curt Westen, Esq. General Counsel HealthMarkets, Inc. 9151 Boulevard 26 North Richland Hills, TX 76180 ***@*** | |
With a copy to: | ||
Dean Richlin, Esq. Foley Hoag LLP 155 Seaport Boulevard Boston, MA 02210 ***@*** |
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Justice of the Superior Court | ||||
Approved by: | ||||||
COMMONWEALTH OF MASSACHUSETTS Martha Coakley, Attorney General | THE MEGA LIFE AND HEALTH INSURANCE COMPANY, MID-WEST NATIONAL LIFE INSURANCE COMPANY OF TENNESSEE, and HEALTHMARKETS, INC. By their attorneys, | |||||
/s/ Thomas M. OBrien | /s/ Dean Richlin | |||||
Thomas M. OBrien, BBO # 561863 Emiliano Mazlen BBO # 600912 Assistant Attorneys General Health Care Division One Ashburton Place Boston, MA 02108 (617)  ###-###-#### | Dean Richlin, Esq., BBO # 419200 Colin J. Zick, Esq. BBO # 556538 Foley Hoag LLP 155 Seaport Blvd. Boston, MA ###-###-#### (617)  ###-###-#### | |||||
Dated: August 31, 2009 |
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9151 Boulevard 26
North Richland Hills, TX 76180-5605
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