Justia Health Law Opinion SummariesArticles Posted in Delaware Supreme Court
State Farm v. Spine Care Delaware
A superior court determined State Farm Mutual Auto Insurance Company and State Farm Fire and Casualty Company’s (collectively, “State Farm”) payment practices with Spine Care Delaware, LLC (“SCD”) for medical fees incurred by its Personal Injury Protection (“PIP”) insureds in connection with covered multi-injection spine procedures contravened 21 Del. C. 2118(a)(2). When State Farm received SCD’s charges for a multi-injection procedure performed on one of its PIP insureds, it unilaterally applied a Multiple Payment Reduction (“MPR”) to the charges for injections after the first injection in a manner consistent with Medicare guidelines, paying SCD less than what it charged. SCD sought a declaration that State Farm's application of its MPRs was inconsistent with section 2118(a)(2)’s requirement of reasonable compensation for covered medical expenses, and sought a declaration that State Farm had to pay SCD any reasonable amount charged for PIP-related medical expenses, without applying MPRs. Both parties then moved for summary judgment. The superior court held that State Farm failed to show that the MPR reductions correlated to reasonable charges for the multiple-injection treatments, and thus contravened section 2118(a)(2). On appeal, State Farm contended the superior court incorrectly placed the burden of proof on State Farm to demonstrate that its application of MPRs was reasonable, and that SCD failed to meet its burden of demonstrating that State Farm’s application of MPRs was a failure to pay reasonable and necessary expenses under the statute. Alternatively, State Farm argued that even if it had the burden of proof, it satisfied that burden. The Delaware Supreme Court agreed with State Farm's first premise, that the superior court erred in assigning State Farm the burden of proof. Judgment was reversed and the matter remanded for further proceedings. View "State Farm v. Spine Care Delaware" on Justia Law
Prunckun v. Delaware Dept. of Health & Social Services
Ashlee Oldham and Robert Prunckun (collectively, “Recipients”) were the only two Delaware Medicaid recipients housed at Judge Rotenberg Center (“JRC”), a facility in Massachusetts and the only facility in the United States known to use electric shock therapy as part of their comprehensive behavioral treatment plans. These services were covered by Medicaid with the knowledge and approval of Delaware’s Department of Health and Social Services (“DHSS”). in 2012, the Center for Medicare and Medicaid Services (“CMS”) advised the Massachusetts state agency responsible for Medicaid administration that continued use of electric shock therapy would place that state’s waiver program in jeopardy of losing federal funding. Following CMS’s letter to Massachusetts, Delaware took measures to avoid placing its own Home and Community Based Services (“HCBS”) waiver program at risk. DHSS finally terminated JRC as a qualified provider after JRC refused to cease using electric shock therapy. Although the procedural history was complex, the gist of Appellants’ challenge on appeal to the Delaware Supreme Court was that they were denied due process because Delaware’s administrative hearing officer bifurcated proceedings to address what she concluded was a threshold issue, namely, whether electric shock therapy was a covered Medicaid service under the Medicaid HCBS Waiver program. Instead, Recipients contended they should have been allowed to introduce evidence that electric shock therapy was medically necessary, and that by removing shock services, DHSS threatened Recipients’ ability to remain in a community-based setting (a conclusion they desired to prove through evidence and expert testimony). The Supreme Court determined the hearing officer's determination that electric shock therapy was not a covered service under federal and state law was supported by substantial evidence and free from legal error, and affirmed the district court. View "Prunckun v. Delaware Dept. of Health & Social Services" on Justia Law
Teamsters Local 237 Welfare Fund, et al. v. AstraZeneca Pharmaceuticals LP
A group of New York-based third party payor health insurers (“TPPs”) that provided prescription drug benefits to union members appealed a Superior Court judgment dismissing with prejudice their second amended complaint. At issue were claims brought by the TPPs under various state consumer fraud laws against AstraZeneca Pharmaceuticals LP, and Zeneca Inc. (collectively “AstraZeneca”). The TPPs alleged that AstraZeneca falsely advertised its more expensive patented prescription drug "Nexium" as superior to the less expensive generic drug "Prilosec," causing the TPPs to overpay for Nexium when generic Prilosec would have sufficed. After conducting an extensive choice of law analysis, the Superior Court determined that New York law controlled the TPPs’ claims. The court then held that the TPPs failed to state a claim under New York’s consumer fraud statute for failure to allege legally sufficient causation. The TPPs appealed, arguing the Superior Court's choice of law analysis was flawed, and that the Superior Court's causation analysis was equally flawed. After a careful review of the record on appeal, the Delaware Supreme Court affirmed the ultimate judgment of the Superior Court, finding it not necessary to discuss whether the Superior Court correctly analyzed the choice of law issue, because under either state consumer fraud statute the TPPs could not recover damages as a matter of law. View "Teamsters Local 237 Welfare Fund, et al. v. AstraZeneca Pharmaceuticals LP" on Justia Law
Delaware Board of Nursing v. Gillespie
The Board appealed from a Superior Court decision reversing the Board's decision to suspend the nursing licenses of appellee. The Board suspended appellee's licenses for two years based upon a finding that she failed to report child sexual abuse as required by state statute. The Board contended that it did not err in finding that appellee committed the violations at issue and the Board submitted that its decision finding a violation of the applicable provisions was supported by substantial evidence. Appellee argued that the Board's appeal was barred by a conflict of interest. The court concluded that the Board's contentions were without merit. Therefore, the judgment of the Superior Court must be affirmed and the court need not reach the conflict of interest issue. View "Delaware Board of Nursing v. Gillespie" on Justia Law
Dept. of Health & Social Servs v. Jain
The Delaware Department of Health and Social Services (DHSS) appealed from a Superior Court order reversing a DHSS Administrative Hearing Officer's decision to place Madhu Jain on the Adult Abuse Registry for three years, because Jain had "neglected" a patient as defined by 11 Del. C. 8564(a)(8) and 16 Del. C. 1131(9). On appeal, DHSS claimed that the Superior Court erroneously concluded that DHSS had failed to show that Jain neglected the patient within the meaning of the two statutes because Jain's conduct breached basic, fundamental nursing standards. The court held that the facts did not support a finding that Jain committed an act of neglect, recklessly, knowingly, or intentionally. Therefore, the court affirmed the Superior Court's judgment.
Reddy, M.D. v. The PMA Ins. Co., et al.
Defendant appealed from a final judgment that was entered in favor of plaintiffs, as subrogees of Harbor Health Care and Rehabilitation Center, Inc. (collectively, "Harbor Health"). At issue was whether the superior court erred as a matter of law in denying his motion for summary judgment and renewed motion for judgment as a matter of law, both based upon the statute of limitations. Also at issue was whether the superior court erred as a matter of law in denying defendant's motion for judgment as a matter of law following the conclusion of plaintiffs' case-in-chief because plaintiffs failed to establish the element of causation in their claim against him. The court held that Harbor Health's claim for contribution was timely filed where a three-year statute of limitations separately governed contribution claims. The court also held that there was sufficient record evidence to support the jury's determination that the failure to have corrective surgery performed for the patient at issue was proximately caused by defendant's negligent conduct. Accordingly, the judgment of the superior court was affirmed.