CLARK, Justice.
A putative class action was filed against West Calcasieu Cameron Hospital (hereinafter referred to as "WCCH") for alleged violations of La. R.S. 22:1874, also known as the "Balance Billing Act." This suit was expanded to name several health insurance issuers as defendants. The current claim under review is asserted by the plaintiff Laura Delouche against her insurer, Louisiana Health Service & Indemnity Company, d/b/a Blue Cross and Blue Shield of Louisiana (hereinafter referred to as "Blue Cross"). We granted certiorari to determine whether a cause of action exists, whereby Delouche can pursue a legal remedy against Blue Cross. For the reasons that follow, we affirm the lower court's denial of Blue Cross's exception of no cause of action and remand for proceedings consistent with this opinion.
On or about August 13, 2010, Delouche was injured in an automobile accident and
At the time of treatment, Delouche notified WCCH that she was insured by Blue Cross; however, WCCH refused to accept her insurance and ignored the agreed upon reduced price. Instead, WCCH charged Delouche the full, undiscounted amount of $718.00 and asserted a lien against any tort recovery Delouche may receive from a third party as a result of the automobile accident. This practice of rejecting insurance and collecting or attempting to collect full charges is referred to as "balance billing" and is prohibited by law. See La. R.S. 22:1874. Delouche sued WCCH for this practice of over-billing.
In a supplemental petition, Delouche added Blue Cross as a defendant, claiming Blue Cross was liable for WCCH's failure to perform. Blue Cross filed several exceptions, including an exception of no cause of action. The trial court overruled the exception, and the court of appeal denied writs, with one dissenting judge noting that a full opinion was required.
Blue Cross filed a writ application with this court. We granted certiorari to determine whether the factual allegations in Delouche's petition give rise to any cause of action against Blue Cross.
The peremptory exception of no cause of action is designed to test the legal sufficiency of a petition by determining whether a party is afforded a remedy in law based on the facts alleged in the pleading. La.Code Civ.P. art. 927; Everything on Wheels Subaru, Inc. v. Subaru South, Inc., et al., 616 So.2d 1234, 1235 (La.1993). All well-pleaded allegations of fact are accepted as true and correct, and all doubts
In Greemon v. City of Bossier City, 2010-2828, p. 8 (La.7/1/11), 65 So.3d 1263, 1268, this court explained Louisiana's fact pleading system:
The sufficiency of a petition subject to an exception of no cause of action is a question of law, and a de novo standard is applied to the review of legal questions; this court renders a judgment based on the record without deference to the legal conclusions of the lower courts. See Foti v. Holliday, 2009-0093, p. 6 (La.10/30/09), 27 So.3d 813, 817.
To determine whether any valid cause of action exists, we must examine the factual allegations contained in the petition. We note that typically evidence is not allowed to be admitted to support or controvert an exception of no cause of action. See La. Code Civ. P. art. 931. However, the parties, without objection, admitted the contracts at issue, thereby expanding what the court may examine in determining whether a legal remedy exists. (See City of New Orleans v. Bd. of Directors of Louisiana State Museum, 98-1170 (La.3/2/99), 739 So.2d 748, 756, wherein the court recognized the jurisprudential exception to the rule that allows evidence admitted without an objection to enlarge the pleadings.)
Delouche alleges Blue Cross "agreed and promised that if its insureds were treated by a contracted health care provider, such as WCCH, the provider would submit claims to the insurer, and that all that the insured would be required to pay to the provider for covered services would be any deductible, co-payment, co-insurance or other amounts as provided for in the policy of insurance as the insured[']s responsibility." Delouche alleges that WCCH did not comply with its obligations. Thus, as averred in her petition, Blue Cross is liable for WCCH's failure to perform as promised by Blue Cross. The
In support of her lawsuit, Delouche contends the petition clearly states a cause of action. She, an insured, entered into a contract with Blue Cross whereby she agreed to pay premiums in exchange for the availability of negotiated group discounts for health care costs.
Blue Cross, in defending its exception of no cause of action, argues the sole object of the contract between itself and its insured, Delouche, is payment of covered medical expenses. Blue Cross asserts it
The trial court, in overruling Blue Cross's exception, found there to be a valid cause of action under La. Civ.Code art. 1977, which provides:
This civilian concept known as promesse de porte-fort contemplates a contract in which the object is that a third party will undertake a certain obligation" in the event of non-performance of that obligation by the third party, the promisor becomes liable to the promisee. Blue Cross, as mentioned above, argues the object of the contract is solely to pay for covered health care services. Delouche acknowledges that payment of covered medical bills is an obvious object of the contract, but she contends the object extends beyond mere payment based on the terms and conditions of the contract of insurance. Rather, the object is to also secure reduced health care costs and tender payment for those negotiated, discounted costs.
In this two-contract health care system that affects the majority of health insurance policies in this state, the insurance issuer, such as Blue Cross, promises to its insureds, such as Delouche, coverage and the availability of discounted rates based on the existence of its contract with its contracted providers, such as WCCH. The purpose of a health insurance contract and the very reason insureds obligate themselves to the payment of premiums and a restricted choice of in-network providers, is to receive coverage and the benefits of negotiated, reduced health care costs. To narrowly construe the object to mean only payment of covered charges, as Blue Cross argues, ignores the raison d'etre of the contract: an economic benefit to the insured. Holding otherwise is illogical based on the terms of this high deductible policy, where the promised reduced rate attaches the instant a medical charge is incurred, regardless of whether a deductible has been satisfied. The insurance policy at issue promised that even the out-of-pocket expenses that count towards Delouche's deductible would be subject to a discount.
The actual billing of this promised, discounted charge is performed by a third party. Thus, Blue Cross is promising that a third party will render a performance, which fits squarely within the context of La. Civ.Code art. 1977.
Blue Cross avers this interpretation as argued by Delouche amounts to suretyship or vicarious liability; however, we observe that Blue Cross itself entered into the contract with Delouche and made certain assurances. The fact that Blue Cross could only deliver based on third party performance does not make Blue Cross immune to liability. Thus, we find, at a minimum, the material facts alleged in the petition are sufficient to survive an exception of no cause of action under La. Civ. Code art. 1977. We expressly offer no opinion as to the success of this claim, only that Delouche is afforded the right to judicially assert an action against Blue Cross.
Blue Cross acknowledges that WCCH, as the provider, contractually agreed to file claims for services rendered to insureds for payment by Blue Cross. Blue Cross further points to policy language that instructs an insured how to file his/her own claim. Blue Cross argues that, despite these provisions, no claim for the treatment after the accident was ever filed in this matter by either WCCH or Delouche. Without a submitted claim, there was nothing to process. Thus, Blue Cross avers it cannot be liable. Next, Blue Cross argues Delouche did not meet any of her $1,700.00 deductible and because the charge of $718.00 was less than the deductible, Blue Cross would not pay any of this amount regardless of the circumstances. Lastly, in defense, Blue Cross relies on the following contractual language to support its argument that its liability is limited by virtue of the policy between itself and Delouche:
Non Responsibility for Acts of Providers:
We find these factual defenses are relevant to the merits of this case and are not appropriate to consider at this stage of the proceeding. Accordingly, we expressly decline to entertain them and offer no conclusions as to the success of the underlying claims or defenses of Delouche and Blue Cross, respectively.
To conclude, we find Delouche's petition sufficiently alleges facts to survive Blue
GUIDRY, Justice, dissents and assigns reasons.
I respectfully dissent from the majority's holding that the plaintiff has asserted a cause of action against her health insurer under either the Health Care and Consumer Billing and Disclosure Protection Act, La. Rev. State. 22:1871 et seq. (commonly known as the "Balance Billing Act") or La. Civ.Code art. 1977.
The function of the peremptory exception of no cause of action is to question whether the law extends a remedy to the plaintiff under the factual allegations of the petition. Kinchen v. Livingston Parish Council, 07-0478 (La.10/16/07), 967 So.2d 1137. Here, the plaintiff seeks to recover damages against her health insurer for her health care provider's alleged violations of the Balance Billing Act. However, in my view, the legislature has not provided the insured a private right of action under the Balance Billing Act against the health care provider for improper billing or collection practices; therefore, it certainly has not provided the insured with an action against her health insurer for her health care provider's alleged violation of the Act. As I explained in my dissent in the companion case of Yana Anderson v. Ochsner Health System and Ochsner Clinic Foundation, 13-CC-2970 (La.7/1/14), ___ So.3d ___, 2014 WL 2937101, (Guidry, J., dissenting), the legislature has expressly provided two remedies for a health care provider's violations of the Balance Billing Act. Specifically, an insured may file a complaint with the Consumer Protection Division of the Department of Justice pursuant to La.Rev.Stat. 22:1877(A)(1), which delegates to the attorney general the discretion to pursue remedies under the Louisiana Unfair Trade Practices Act, La.Rev.Stat. 51:1401 et seq. Alternatively, in the event the health care provider maintains an action at law seeking to enforce a lien against the insured for an amount in excess of the reimbursement rate, the insured is entitled to attorneys fees and costs if the suit is successfully defended. La.Rev.Stat. 22:1874(B).
I also find no merit in the majority's reliance on La. Civ.Code art. 1977 to circumvent the insured's lack of privity of contract to support her breach of contract claims. The plaintiff pleaded the provisions of not only her contract with her health insurer, but also the provider agreement between the health insurer and the health care provider. While the majority concedes the insured is not a party to the provider agreement, it suggests by virtue of the insured's contract with her insurer, who allegedly promised discounted rates, that the insurer has guaranteed the health care provider's performance of its obligations under the Balance Billing Act. However, there is no promesse de portefort as alleged by the insured, because if there is no private right of action for an insured against the health care provider who violates the Act, there can be no cause of action by the insured against the health insurer for its failure to guarantee the performance of the health care provider under the Balance Billing Act.
GUIDRY, J., dissents and assigns reasons.
VICTORY, J., dissents for the reasons assigned by J. GUIDRY.