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Robinson v. Montana State Fund

Court of Workers Compensation of Montana

June 29, 2005

JANIE L. ROBINSON Petitioner
v.
MONTANA STATE FUND Respondent/Insurer.

          Submitted: February 22, 2005

          ORDER GRANTING PARTIAL SUMMARY JUDGMENT

          MIKE McCARTER JUDGE.

         Summary: Cross-motions for summary judgment were filed with respect to the petitioner's constitutional challenge to the managed care provisions found in Title 39, ch. 71, part 11, MCA (1995).

         Held: Petitioner lacks standing to challenge the constitutionality of statutes which have not been applied to her and where she has not been threatened with their application.

         Topics:

Constitutional Law: Standing. Only those affected by a statute can challenge the constitutionality of the statute.
Constitutional Law: Standing. Where the claimant has not been required to seek her medical care from a managed care organization or preferred provider organization, and there is no indication that she will ever be required to do so, she lacks standing to challenge the constitutionality of statutes authorizing insurers to refer claimants to managed care organizations and preferred provider organizations for medical care related to their industrial injuries.
Managed Care Organizations. Where a claimant has not been required to seek her medical care from a managed care organization or preferred provider organization, and there is no indication that she will ever be required to do so, she lacks standing to challenge the constitutionality of statutes authorizing insurers to refer claimants to managed care organizations and preferred provider organizations for medical care related to their industrial injuries.

         ¶1 The petition herein sets out two causes of action. The first challenges the constitutionality of sections 39-71-1101 through 39-71-1108, MCA (1995). The second alleges that medical benefits have been unreasonably delayed and seeks a penalty. Both parties have moved for summary judgment with respect to the first cause of action.

         Uncontested Facts

         ¶2 The respondent, Montana State Fund (State Fund), filed the first motion for summary judgment. The motion was supported by two affidavits, as well as the pleadings in the case. The motion sets forth five facts. None have been controverted by the petitioner (claimant), therefore, they are deemed true for purposes of the motion. Those facts, as appear from the affidavits and pleadings, are as follows:[1]

¶2a The petitioner has filed several workers' compensation claims; however, the only claim at issue in the present case is one for an alleged injury on July 4, 1996.
¶2b The alleged injury was for a possible heat stroke suffered by the claimant while baling hay on July 4, 1996.
¶2c The claimant's employer was insured by the State Fund on the date of the alleged injury.
¶2d The State Fund utilizes a managed care organization (hereinafter "MCO" or "MCOs") in the management of some of its claims. The MCO it uses is Montana Health Systems. However, the claimant has never used that MCO.
¶2e With respect to the July 4, 1996 claim, the claimant's only involvement with a preferred provider organization (hereinafter "PPO" or "PPOs") has been since May 2004 with Plaza Pharmacy in Great Falls, Montana. Plaza Pharmacy became a PPO member pharmacy in May 2004. However, the claimant used the pharmacy prior to its becoming a PPO member.

         ¶3 In addition to the foregoing facts, two other facts are apparent from the pleadings and the parties' briefs, and should be expressly stated. Those facts are:

¶3a The State Fund accepted liability for the claimant's July 4, 1996 injury.
¶3b The State Fund has paid medical benefits with respect to the claim.

         ¶4 The claimant has, on her part, provided the Court with numerous other facts she contends are uncontested. Those facts relate to specific medical care the claimant has sought or received and the State Fund's involvement in that care by way of questions it put to medical providers, its authorization for specific treatment, and its requests for and monitoring of specific treatment plans. In view of this Court's determination that the claimant lacks standing to pursue her first cause of action, it is unnecessary to sort through all of the facts she proffers. However, specific examples from her proffer will be set out in the discussion that follows:

         STANDARD OF REVIEW

         ¶5 The moving party must establish that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law. Rule 24.5.329; Farmers Union Mut. Ins. Co. v. Horton, 2003 MT 79, ¶ 10, 315 Mont. 43, 67 P.3d 285. The moving party need not demonstrate that all facts are uncontested, only that the facts material to the motion and to the point of law upon which the summary judgment motion is based are not genuinely disputed.

         SUMMARY JUDGMENT ISSUES

         ¶6 In her first cause of action, the claimant requests the Court to enter a declaratory judgment finding sections 39-71-1101 through 39-71-1108, MCA (1995), unconstitutional. She urges that the managed care provisions of these sections violate the Individual Dignity Clause - Article II, § 3 - of the Montana Constitution and the Privacy Clause - Article II, § 10 - of the Montana Constitution.

         ¶7 The claimant filed a motion for summary judgment on the merits of her claim. On its part, the State Fund has filed a motion for partial summary judgment seeking to dismiss the constitutional challenge on the ground that the claimant lacks standing to attack the managed care statutes. The State Fund further argues that the statutes are in any event constitutional.

         STATUTES IN QUESTION

         ¶8 Part 11, chapter 71 of Title 39, is entitled "Managed Care and Preferred Provider Organizations." A copy of the 1995 version of the part is appended to this decision.

         ¶9 As a general matter, Part 11 provides that insurers may require claimants to seek medical care for workers' compensation injuries from MCOs and PPOs.

         ¶10 Part 11 does not define "managed care" or "managed care organization."[2] It does describe a "managed care system" in very general terms as

a program organized to serve the medical needs of injured workers in an efficient and cost-effective manner by managing the delivery of medical services for a defined population of injured workers, pursuant to 39-71-1101, through appropriate health care professionals.

§ 39-71-1103(1), MCA (1995). "Managed care" is generally understood as signifying "a contractual arrangement whereby a third-party payer (e.g., insurance company, government agency, or corporation) mediates between physicians and patients, negotiating fees for service and overseeing the types of treatment given." Stedman's Online Medical Dictionary, 27th ed.

         ¶11 Similarly, part 11 provides no definition of a PPO. However, the term is generally understood to mean a group or network of health care providers who together contract to provide medical goods or services to PPO members or beneficiaries. Stedman's Online Medical Dictionary, 27th ed., defines the term as "a health care delivery model that uses a panel of eligible physicians." The services of preferred providers are typically provided through contracts with insurers, employers, governmental entities, or MCOs.

         ¶12 Section 39-71-1105, MCA (1995), provides for the establishment and certification of MCOs. Subsection (1) provides in relevant part:

(1) A health care provider, a group of medical service providers, or an entity with a managed care organization may make written application to the department to become certified under this section to provide managed care to injured workers for injuries that are covered under this chapter or for occupational diseases that are covered under the Occupational Disease Act of Montana. . . . Certification is through the Department of Labor and Industry. § 39-71-1105(2)-(4), MCA (1995).

         ¶13 To be certified as an MCO, the organization must provide a list of names of individual providers who will be providing medical services the MCO beneficiaries, the names of those providers who will serve as treating physicians, and descriptions of "the times, places, and manner" the MCOs will provide both primary and secondary medical services.[3] § 39-71-1105(3), MCA (1995).

         ¶14 The PPO provision allows for the establishment of organizations of providers to provide medical goods and services in conjunction with or supplemental to those provided by an MCO. Section 39-71-1102, MCA (1995), reads in relevant part:

In order to promote cost containment of medical care provided for in 39-71-704, development of preferred provider organizations by insurers is encouraged. Insurers may establish arrangements with suppliers of soft and durable medical goods and medical providers in addition to or in conjunction with managed care organizations. Workers' compensation insurers may contract with other entities to use the other entities' preferred provider organizations. . . .

         (Emphasis added.)

         ¶15 Part 11 permits but does not require insurers to contract with MCOs to provide medical services to injured workers. Section 39-71-1103(3), MCA (1995), states that "[i]nsurers may contract with certified managed care organizations for medical services for injured workers." (Emphasis added.)

         ¶16 If an insurer does contract with one or more MCOs, it may require the worker to seek medical care through a designated MCO if the injury results in a loss of wages, permanent impairment, treatment or evaluation by a specialist, or ...


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