On Tuesday, the Western District of Texas issued a decision in a case brought against Centene Management Company, which concerns with an Affordable Care Act (ACA) Ambetter insurance plan and the level of benefits promised versus the level of benefits provided.
The plaintiffs purchased the insurance coverage from the ACA marketplace to provide health insurance coverage. After presenting the policies, the plaintiffs discovered that there were very few “in network” providers directly contracted with the plan and that the insurance plan denied coverage for any visits to out of network health providers. The plaintiffs sued, alleging breach of contract, breach of express warranty, and violations of the Texas Deceptive Trade Practices Consumer Protection Act (DTPA). The defendants addressed each claim separately but also alleged that all of the claims should be dismissed under the filed rate doctrine.
The opinion explained that the filed rate doctrine mandates deference by the court to administrative bodies that are created for the direct purpose of regulating an industry. This deference specifically also applies to pricing schedules that have been created or approved by the regulatory body, such as the pricing schedule for monopolistic utilities such as the electric, water and sewer, and gas utilities. The court denied this overall motion, indicating that while the Texas Department of Insurance collected policy rates, it expressly averred setting the rates or approving the rates and disclaimed any authority over the rate setting process, meaning that the rates were not controlled by an entity that was due deference.
The court also dismissed the second and third claim of the complaint, indicating that a claim for Breach of Express Warranty, under Texas law, must allege a breach beyond that claimed under the breach of contract claim. The court also held that the DTPA claim was beyond the statute of limitations and should be properly dismissed.