throbber
Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 1 of 16
`
`Lynn M. Allen, State Bar Number 012612
`lallen@tysonmendes.com
`TYSON & MENDES, LLP
`7910 East Thompson Peak Parkway, Suite 101
`Scottsdale, Arizona 85255
`Telephone: (480) 571-5031
`Facsimile: (480) 245-5424
`Attorneys for Plaintiff
`
`
`
`
`
`
`
`
`
`
`UNITED STATES DISTRICT COURT
`
`DISTRICT OF ARIZONA
`
`
`
`
`Allied World Specialty Insurance Company
`f/k/a Darwin National Assurance Company,
`
` Plaintiff,
`vs.
`
`
`Blue Cross Blue Shield Of Arizona, Inc.,
`
` Defendants.
`
`
`)
`)
`)
`)
`)
`)
`)
`)
`)
`)
`
`No.
`
`COMPLAINT FOR DECLARATORY
`JUDGMENT
`
`
`
`
`
`
`
`Plaintiff, Allied World Specialty Insurance Company f/k/a Darwin National Assurance
`
`Company (“Allied World”), brings this action seeking declaratory relief against the Defendant,
`
`Blue Cross & Blue Shield of Arizona, Inc. (“BCBS-AZ”), and alleges the following:
`
`Parties, Jurisdiction and Venue
`
`1.
`
`This is a diversity action for declaratory relief pursuant to 28 U.S.C. § 2201 to
`
`declare the rights and other legal relations of the parties regarding an insurance policy issued by
`
`Allied World.
`
`2.
`
`Allied World is a corporation organized and existing under the laws of the State
`
`of Delaware with its principal place of business in the State of New York.
`
`3.
`
`BCBS-AZ is a corporation organized and existing under the laws of the State of
`
`Arizona with its principal place of business in the State of Arizona.
`
`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`11
`
`12
`
`13
`
`14
`
`15
`
`16
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`

`

`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`11
`
`12
`
`13
`
`14
`
`15
`
`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 2 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`4.
`
`This Court has subject matter jurisdiction over this case pursuant to 28 U.S.C. §
`
`1332(a). There is complete diversity of citizenship between Allied World and BCBS-AZ. The
`
`amount in controversy exceeds $75,000.00, exclusive of interest and costs.
`
`5.
`
`This Court has personal jurisdiction over BCBS-AZ, and venue is proper in this
`
`District under 28 U.S.C. § 1391.
`
`6.
`
`This action is brought pursuant to 28 U.S.C. § 2201, which provides that the
`
`Court may declare the rights and other legal relations of the parties. Allied World and BCBS-
`
`AZ are both parties having an interest in the insurance policy referenced herein.
`
`BACKGROUND FACTS
`
`The MDL Action
`
`7.
`
`Beginning in 2012, numerous class action lawsuits were filed against multiple
`
`Blue Cross Blue Shield entities or member plans (“Blues”) and the Blue Cross Blue Shield
`
`16
`
`Association (“BCBSA”) alleging violations of federal antitrust laws. One set of cases was filed
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`by “Providers” (physicians and other healthcare providers who render services to persons
`
`insured under Blue Plans), and another set of cases was filed by “Subscribers” (persons and
`
`businesses that have Blue Plan healthcare insurance policies)
`
`8. While brought by different groups of plaintiffs, the lawsuits each allege
`
`generally that the Blues and the BCBSA conspired to leverage their economic power and market
`
`dominance to under-compensate healthcare providers for their services and to increase
`
`healthcare costs to subscribers by coordinating their operations and limiting their activities
`
`through restrictions in their trademark licenses.
`
`
`
`
`
`
`
`
`
`
`
`2
`
`
`
`

`

`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 3 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`9.
`
`On December 12, 2012, the Judicial Panel on Multidistrict Litigation
`
`consolidated both the Provider and Subscriber lawsuits and transferred them to the United States
`
`District Court for the Northern District of Alabama, thus creating the MDL litigation referred to
`
`as In Re: Blue Cross Blue Shield Antitrust Litigation, Master File No 2:13-cv-20000-RDP (the
`
`“MDL Action”). A copy of the December 12, 2012 MDL Transfer Order is attached hereto as
`
`Exhibit 1.
`
`10.
`
`In consolidating the Providers’ and the Subscribers’ actions, the MDL Panel
`
`found: “Here, the actions involve substantial common questions of fact relating to the state
`
`11
`
`BCBS entities’ relationship with the national association, BCBSA, and the licensing agreements
`
`12
`
`13
`
`14
`
`15
`
`that limit the Blue Plans’ activity to exclusive service areas, among other restrictions.” MDL
`
`Transfer Order at 2.
`
`11.
`
`Pursuant to an Order issued by the MDL Court, two consolidated complaints
`
`16
`
`were filed in the MDL Action on July 1, 2013, one for the “provider track” (the “Provider
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`Complaint”) and one for the “subscriber track” (the “Subscriber Complaint”), both of which
`
`have been amended several times. A copy of the Consolidated Fourth Amended Provider
`
`Complaint is attached hereto as Exhibit 2; a copy of the Subscriber Track Fourth Amended
`
`Consolidated Class Action Complaint is attached hereto as Exhibit 3.
`
`12. BCBS-AZ was first named as a defendant in each the Provider Complaint and in
`
`the Subscriber Complaint when the consolidated complaints were filed on July 1, 2013.
`
`13.
`
`The Provider Complaint alleges that the Blues have been engaged for many
`
`years in an agreement not to compete against one another, but instead to cooperate and
`
`
`
`
`
`
`
`
`
`
`
`3
`
`
`
`

`

`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 4 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`coordinate their activities on a nationwide basis in order to maximize their profits. The
`
`Complaint claims that the Blues agreed to cease competing and to impose operational uniformity
`
`on themselves decades ago by carving out exclusive service areas, setting up their national
`
`programs (including Blue Card), and establishing BCBSA’s uniform rules and regulations. The
`
`Blues allegedly formalized their cooperation agreement through restrictions in their trademark
`
`licenses, such as the requirement of mandatory participation in the national programs.
`
`14.
`
`The alleged conspiracy has perpetuated and strengthened the dominant market
`
`position each Blue enjoys in its specifically defined geographic market which, in turn, has
`
`11
`
`enabled the Blues to force healthcare providers to accept anticompetitive rates and terms. The
`
`12
`
`13
`
`14
`
`15
`
`Provider Complaint alleges that healthcare providers have been subjected to lower rates and less
`
`favorable terms than would have been the case in the absence of the conspiracy.
`
`15.
`
`The Provider Complaint seeks injunctive relief prohibiting the Blues, including
`
`16
`
`BCBS-AZ, from entering into, honoring, or enforcing any agreements that restrict territories or
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`geographic areas, enjoining the Blues from utilizing the Blue Card Program to pay healthcare
`
`providers, and enjoining the Blues from developing any other program or structure that is
`
`intended to fix, or has the effect of fixing, prices paid to healthcare providers. The Provider
`
`Complaint also seeks money damages in the form of treble damages.
`
`16.
`
`The Subscriber Complaint similarly alleges that the Blues have been engaged for
`
`many years in an agreement not to compete against one another, but instead to cooperate and
`
`coordinate their activities on a nationwide basis in order to maximize their profits. The
`
`Subscriber Complaint alleges that the Blues agreed to cease competing and to impose
`
`
`
`
`
`
`
`
`
`
`
`4
`
`
`
`

`

`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 5 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`operational uniformity on themselves decades ago by carving out exclusive service areas and
`
`establishing BCBSA’s uniform rules and regulations, including BCBSA’s Membership
`
`Standards and Guidelines. The Blues allegedly formalized their cooperation agreement in their
`
`trademark licenses.
`
`17.
`
`The Subscriber Complaint seeks injunctive relief prohibiting the Blues, including
`
`BCBS-AZ, from entering into, honoring, or enforcing any agreements that restrict territories or
`
`geographic areas, and it also seeks to eliminate restrictions on the Blues’ activities. The
`
`Complaint further seeks money damages in the form of treble damages of the amount by which
`
`11
`
`the plaintiffs allege premiums were artificially inflated above their competitive levels.
`
`12
`
`13
`
`14
`
`15
`
`18. On November 30, 2020, the Court in the MDL Action preliminarily approved a
`
`settlement of the Subscribers’ claims, pursuant to which the Blues agreed to pay $2.67 billion. A
`
`copy of the Court’s Memorandum Opinion and Order Preliminarily Approving Settlement, Plan
`
`16
`
`of Distribution, and Notice Plan, and Directing Notice to the Class is attached as Exhibit 4.
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`19.
`
`The Provider Complaint and the Subscriber Complaint are based upon the same
`
`or related conduct of the Blues relating to the Blues’ “relationship with the national association,
`
`BCBSA, and the licensing agreements that limit the Blue Plans’ activity . . . .” MDL Transfer
`
`Order at 2. The Complaints differ only with respect to the alleged harm to the Providers and to
`
`the Subscribers. Both Complaints seek damages in excess of this Court’s jurisdictional limit and
`
`invoke federal question jurisdiction.
`
`Prior Related Litigation – Love
`
`20. BCBS-AZ was also a defendant in a prior class action litigation styled Love v.
`
`5
`
`
`
`
`
`
`
`
`
`
`
`
`
`

`

`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 6 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`Blue Cross Blue Shield Assoc., No. 03-21296 (S.D. Fla.) (originally titled Thomas v. Blue Cross
`
`Blue Shield Assoc.) (“Love”). Love was part of the MDL proceeding created in April 2000, and
`
`styled In re Managed Care Litigation, No. 1:00-MDL-1334. A copy of Plaintiffs’ Sixth (and
`
`final) Amended Class Action Complaint is attached as Exhibit 5.
`
`21.
`
`Like the MDL Action, Love was based on the theory that the Blues for many
`
`years have not competed against one another, but instead have engaged in an agreement to
`
`cooperate and coordinate their activities on a nationwide basis in order to maximize their profits.
`
`22.
`
`The Love plaintiffs alleged that the Blues are not competitors, but instead
`
`11
`
`provide health services only in individual distinct geographic regions, and that the individual
`
`12
`
`13
`
`14
`
`15
`
`16
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`Blues have market power in their respective regions. The plaintiffs further alleged that the Blues
`
`use their market power to harm providers by forcing them to accept unfavorable
`
`reimbursements.
`
`23.
`
`The Blues allegedly agreed to cease competing and to impose operational
`
`uniformity on themselves decades ago by agreeing to operate in distinct geographic regions,
`
`setting up their national programs (including Blue Card), and establishing BCBSA’s uniform
`
`rules and regulations.
`
`24.
`
`The Blues formalized their alleged cooperation agreement in their trademark
`
`licenses. The Complaint cites the absence of Blue-on-Blue competition – and the resulting
`
`market dominance each Blue has acquired as a result – as well as the operational uniformity
`
`among the Blues required by their trademark licenses (including the requirement of mandatory
`
`participation in the Blue Card Program) as evidence that the Blues have conspired.
`
`
`
`
`
`
`
`
`
`
`
`6
`
`
`
`

`

`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 7 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`25.
`
`The plaintiffs in Love alleged that the Blues engaged in a common scheme to
`
`systematically deny, delay, and diminish payments to providers. Similar to the Provider and
`
`Subscriber Complaints, the Love litigation was based on the restrictions in the Blues’ trademark
`
`licenses, on the Blues’ relationship with BCBSA, and on the Blues’ long history and practice of
`
`national coordination and cooperation.
`
`26. Many of the Blues settled the Love litigation through three settlement
`
`agreements that became effective on September 26, 2008, October 3, 2008, and June 19, 2009,
`
`respectively.
`
`27. BCBS-AZ did not enter a settlement, and, in 2009, the Love court dismissed the
`
`Plaintiffs’ Sixth Amended Complaint with prejudice, issuing a Final Judgment in favor of
`
`BCBS-AZ and eight other Blues.
`
`Three Federal Courts Have Held the MDL Action is Related to the Love Litigation
`
`The Blues who had settled in the Love were named as defendants in a subsequent
`
`28.
`
`action styled Musselman v. Blue Cross Blue Shield of Ala., et al., no. 13-20050 (S.D. Fla.), in
`
`which Provider plaintiffs in the MDL Action sought a declaration that the claims in the MDL
`
`Action were not released by the settlement agreements with the Blues in the Love litigation.
`
`29.
`
`The Blues in Musselman moved to dismiss the complaint, arguing that the MDL
`
`Action Provider Complaint (the only complaint at issue in Musselman) “arises out of and relates
`
`to the ‘facts, acts, events … or other matters’ in Love.”
`
`30.
`
`The District Court agreed with the Blues and granted their motion to dismiss,
`
`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`11
`
`12
`
`13
`
`14
`
`15
`
`16
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`holding that:
`
`
`
`
`
`
`
`
`
`
`
`7
`
`
`
`

`

`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`11
`
`12
`
`13
`
`14
`
`15
`
`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 8 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`[The Provider Complaint] arises out of and relates to the “facts, acts, events .
`. . or other matters” in Love. [The Provider Complaint] is based on Plaintiffs’
`allegation that Defendants conspired to “suppress competition and to increase
`their profits . . . by decreasing the rates paid to healthcare providers . . . .”
`Love was based on the similar allegation that the defendants had engaged in a
`common scheme to systematically deny, delay, and diminish the payments due
`to doctors. In short, both complaints are based on allegations that Defendants,
`acting through [the BCBS Association], conspired to reduce provider
`reimbursement.
`
`Musselman v. Blue Cross & Blue Shield of Alabama, No. 13-20050-CV-MORENO, 2013 WL
`
`4496509, at *5 (S.D. Fla. Aug. 20, 2013), aff'd, 684 F. App’x 824 (11th Cir. 2017) (citations
`
`omitted).
`
`31.
`
`The Musselman plaintiffs appealed to the Eleventh Circuit, and the Eleventh
`
`Circuit “affirm[ed] the District Court’s dismissal of the plaintiff-appellants’ complaint under
`
`Federal Rule of Civil Procedure 12(b)(6) on the basis of the District Court’s thorough and well-
`
`reasoned order.” Musselman v. Blue Cross & Blue Shield of Alabama, 684 F. App’x 824, 825
`
`16
`
`(11th Cir. 2017).
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`32.
`
`In the MDL Action, the Provider plaintiffs sought a partial summary judgment
`
`ruling barring Blue defendants, like BCBS-AZ, that were not signatories to the Love settlement
`
`agreements, from asserting any affirmative defenses related to the Love settlement agreements,
`
`such as res judicata, collateral estoppel, release and waiver.
`
`33. BCBS-AZ and other Blues that did not settle in the Love litigation have argued
`
`that they can benefit from the Musselman ruling that the claims in the Antitrust Litigation were
`
`“Released Claims” within the meaning of the Love settlement agreement.
`
`34.
`
`Judge Proctor in the MDL Action agreed, citing Musselman and holding that
`
`
`
`
`
`
`
`
`
`
`
`8
`
`
`
`

`

`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 9 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`“Providers’ claims in this MDL fall squarely within the scope of the Love releases because they
`
`arise from, or are based on, conduct by the Released Parties,” and stating that “The court agrees
`
`with [the Musselman court] ‘that the [Provider] claims are Released Claims’ under the Love
`
`Settlement Agreement.” In re Blue Cross Blue Shield Antitrust Litigation (MDL No. 2406), No.
`
`2:13-CV-20000-RDP, 2018 WL 6333563, at * 7-8 (N.D. Ala. Oct. 17, 2018).
`
`The Excess Policy
`
`35. Allied World issued Excess Insurance Policy No. 0307-1532 to BCBS-AZ for
`
`the policy period January 1, 2013 through January 1, 2014, that provided certain coverage to the
`
`11
`
`insured in excess of this Court’s jurisdictional threshold pursuant to the policy’s terms,
`
`12
`
`13
`
`14
`
`15
`
`16
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`conditions, and exclusions (the “Excess Policy”). A copy of the Excess Policy is attached hereto
`
`as Exhibit 6.
`
`36.
`
`The Insuring Agreement in the Excess Policy provides:
`
`The Insurer will provide the Insured with insurance excess of
`the Underlying Insurance specified in ITEM 4 of the
`Declarations for claims first made against the Insured during
`the Policy Period. Except as otherwise provided in this Policy,
`coverage under this Policy will apply in conformance with the
`terms and conditions of, and endorsements to, the Primary
`Policy and any other Underlying Insurance. In no event will
`the coverage under this Policy be broader than the coverage
`under any Underlying Insurance. Coverage under this Policy
`will attach only after all Underlying Insurance has been
`exhausted by the actual payment of loss by the Underlying
`Insurers and/or the Insured.
`
`
`(Excess Policy, § I.)
`
`37.
`
`Policy Number 1055376365 issued by Travelers Casualty and Surety Company
`
`of America is listed as the Primary Policy in Item 4 of the Excess Policy’s Declarations. A copy
`
`26
`
`of the Primary Policy is attached hereto as Exhibit 7.
`
`
`
`
`
`
`
`
`
`
`
`9
`
`
`
`

`

`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`11
`
`12
`
`13
`
`14
`
`15
`
`16
`
`17
`
`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 10 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`38.
`
`The Private Company Directors and Officers Liability Coverage Section
`
`Insuring Agreement (“D&O Coverage Section”) in the Primary Policy provides insurance as
`
`follows:
`
`The Company will pay on behalf of:
`
`
`***
`C. the Insured Organization, Loss for Wrongful Acts,
`
`resulting from any Claim first made during the Policy Period,
`or if exercised, during the Extended Reporting Period or Run-
`Off Extended Reporting Period.
`
`
`(Primary Policy, D&O Coverage Section § I, Insuring Agreement (C).)
`
`39.
`
`The Primary Policy defines the term “Claim,” in relevant part, as “any civil
`
`proceeding commenced by service of a complaint or similar pleading . . . against an Insured for
`
`a Wrongful Act, provided that Claim does not include any labor or grievance arbitration or
`
`other proceeding pursuant to a collective bargaining agreement.” (Primary Policy, D&O
`
`Coverage Section § III, Definition (A).)
`
`40.
`
`The term “Wrongful Act” is defined, in relevant part, as “any actual or alleged
`
`18
`
`act, error, omission, misstatement, misleading statement or breach of duty or neglect by, or any
`
`matter asserted against, the Insured Organization.” (Primary Policy, § III, Definition (M).)
`
`41.
`
`Pursuant to the Terms and Conditions of the Primary Policy:
`
`All Claims . . . for Related Wrongful Acts will be considered
`as a single Claim . . . for purposes of this Liability Policy. All
`Claims . . . will be deemed to have been made at the time the
`first of such Claims . . . for Related Wrongful Acts was made
`whether prior to or during the Policy Period . . .
`
`
`(Primary Policy, Terms and Conditions § III, Condition (H).)
`
`42.
`
`The Primary Policy defines a “Related Wrongful Act” as “all Wrongful Acts
`
`10
`
`
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`
`
`
`
`
`
`
`
`
`
`

`

`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`11
`
`12
`
`13
`
`14
`
`15
`
`16
`
`17
`
`18
`
`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 11 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`that have as a common nexus, or are causally connected by reason of, any fact, circumstance,
`
`situation, event or decision.” (Primary Policy, Terms and Conditions § II, Definition (X).)
`
`43.
`
`The D&O Policy defines “Loss” as:
`
`Defense Expenses and money which an Insured is legally
`obligated to pay as a result of a Claim, including settlements,
`judgments, back and front pay, compensatory damages, punitive
`or exemplary damages or the multiple portion of any multiplied
`damage award if insurable under the applicable law most
`favorable to the insurability of punitive, exemplary, or
`multiplied damages, prejudgment and postjudgment interest,
`and legal fees and expenses awarded pursuant to a court order
`or judgment. Loss does not include:
`
`1. civil or criminal fines, sanctions, liquidated damages other
`than
`liquidated damages awarded under
`the Age
`Discrimination in Employment Act or the Equal Pay Act,
`payroll or other taxes, or damages, penalties or types of relief
`deemed uninsurable under applicable law; or
`2. any amount allocated to non-covered loss pursuant to
`Section III. CONDITIONS. P. ALLOCATION of the
`Liability Coverage Terms and Conditions.
`
`
`(Primary Policy, D&O Coverage Section § II, Definition (G).)
`
`44.
`
`Insurance afforded by the D&O Coverage Section of the Primary Policy is
`
`subject to the following exclusion: “The Company will not be liable for Loss for any Claim
`
`19
`
`based upon or arising out of the performance of or failure to perform any Managed Care
`
`Activity” (the “Managed Care Activity Exclusion.”) (Primary Policy, Endorsement No. PDO-
`
`19008 Ed. 06-12.)
`
`45.
`
`The term “Managed Care Activity,” is defined in the Primary Policy as:
`
`[A]ny of the following services or activities performed by or on
`behalf of the Insured for or under any . . . health care plan:
`
`1. Provider Selection;
`
`11
`
`
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`
`
`
`
`
`
`
`
`
`
`

`

`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`11
`
`12
`
`13
`
`14
`
`15
`
`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 12 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`2. Utilization Review;
`3. advertising, marketing, selling, enrollment, administration
`or management;
`4. Claims Services;
`5. establishing or maintaining health care provider networks;
`6. reviewing, profiling or tiering quality or costs of, or
`providing quality assurance of, any provider of Medical
`Services;
`7. design or implementation of benefit plans or financial
`incentive plans, including pay for performance programs,
`that compensate providers of Medical Services;
`8. Disease Management;
`9. Health Care Plan Consulting;
`10. risk management services to any provider of Medical
`Services;
`11. Wellness Services;
`12. development or implementation of clinical guidelines,
`practice parameters or protocols; or
`13. triage for payment of Medical Services.
`
`
`(Primary Policy, Endorsement No. PDO-19008 Ed. 06-12.)
`
`46.
`
`Further, Exclusion (B)(1) of the D&O Coverage Section provides that the
`
`16
`
`Primary Policy shall not cover any Loss, other than Defense Expenses, for any Claim based on
`
`or arising out of any Insured:
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`
`
`
`
`
`
`
`
`
`
`a. committing any intentionally dishonest or fraudulent act or
`omission;
`b. committing any willful violation of any statute, rule, or law;
`or
`c. gaining any profit, remuneration or advantage to which such
`Insured was not legally entitled;
`
`
`provided that this exclusion will not apply unless a judgment or
`other final adjudication in the underlying action establishes that
`such Insured committed such intentionally dishonest or
`fraudulent act or omission, or willful violation of any statute,
`rule or law, or gained such profit, remuneration or advantage to
`which such Insured was not legally entitled.
`
`
`12
`
`
`
`

`

`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 13 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`(Primary Policy, D&O Coverage Section § III, Exclusion (B)(1), as amended by Endorsement
`
`LIA-7335.)
`
`
`
`The Parties’ Dispute
`
`47.
`
`In July 2013, when the consolidated complaints in the MDL Action were filed,
`
`BCBS-AZ provided notice to its insurers, including Allied World, requesting coverage under
`
`managed care errors and omissions liability policies, as well as under the D&O policies issued
`
`by Travelers and Allied World.
`
`48. By letter dated April 14, 2014, Allied World noted that all claims submitted for
`
`11
`
`Subscriber and Provider lawsuits consolidated in the MDL Action were being handled as a
`
`12
`
`13
`
`14
`
`15
`
`16
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`single claim, and reserved its rights given that coverage under the Excess Policy only attaches if
`
`all of the underlying insurance is exhausted by payment of covered losses. A copy of Allied
`
`World’s April 14, 2014 letter, is attached hereto as Exhibit 8.
`
`49.
`
`In a letter dated August 27, 2019, after three Federal courts held that the MDL
`
`Action is related to the Love litigation, Allied World denied coverage for the MDL Action under
`
`the Excess Policy due to the applicability of the Managed Care Activity Exclusion. A copy of
`
`Allied World’s August 27, 2019 letter, is attached hereto as Exhibit 9.
`
`50. Upon information and belief, the managed care activities alleged in the MDL
`
`Action are covered under the terms and conditions of the managed care errors and omissions
`
`liability policies issued by other insurers.
`
`51.
`
`In addition, in its August 27, 2019 correspondence, Allied World notified BCBS-
`
`AZ that the Love litigation and the MDL Action constitute Claims for Related Wrongful Acts
`
`
`
`
`
`
`
`
`
`
`
`13
`
`
`
`

`

`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 14 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`and, as such, would be deemed a single Claim made prior to the Policy Period. Allied World
`
`specifically reserved its rights with respect to all exclusions, conditions and terms of the Excess
`
`Policy.
`
`52.
`
`There is a bona fide present dispute between Allied World and BCBS-AZ
`
`regarding whether Allied World’s Excess Policy provides coverage to BCBS-AZ for the MDL
`
`Action.
`
`53. Allied World is entitled to a declaratory judgment construing the Excess Policy
`
`issued to BCBS-AZ, resolving the dispute between the parties, and declaring that Allied World
`
`11
`
`has no liability to BCBS-AZ for any claims, losses, or other damages or liabilities asserted by
`
`claimants in the MDL Action under the Excess Policy.
`
`COUNT I
`
`Declaration of No Coverage under Excess Policy
`
`54. Allied World hereby incorporates by reference and re-alleges, as if fully stated
`
`herein, each and every allegation of Paragraphs 1 through 53 of this Complaint.
`
`55.
`
`There is no coverage for the MDL Action and the cases consolidated therein
`
`under the Excess Policy for the following reasons:
`
`12
`
`13
`
`14
`
`15
`
`16
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`
`
`
`
`
`
`
`
`
`
`(a)
`
`The MDL Action alleges acts done by BCBS-AZ in the performance
`
`of Managed Care Activities. (Primary Policy, Endorsement No.
`
`PDO-19008 Ed. 06-12);
`
`(b)
`
`The MDL Action and the Love litigation are Claims for Related
`
`Wrongful Acts, which are considered a single Claim deemed made
`
`14
`
`
`
`

`

`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`11
`
`12
`
`13
`
`14
`
`15
`
`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 15 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`prior to the Policy Period. (Primary Policy, Terms and Conditions §
`
`III, Condition (H));
`
`(c)
`
`plaintiffs in the MDL Action seek relief, and any settlement or
`
`judgment in the MDL Action would grant relief, that does not
`
`constitute Loss and/or is uninsurable as a matter of law. (Primary
`
`Policy, D&O Coverage Section § II, Definition (G)); and
`
`(d)
`
`the Claim is not covered under the Policy and Allied World has no
`
`obligation to pay any amount under the Policy.
`
`56. Allied World is entitled to a declaratory judgment in its favor, stating that it has
`
`no liability under the Excess Policy issued to BCBS-AZ for any loss or other damage of any
`
`kind as alleged in the MDL Action (or the separate actions consolidated therein) because the
`
`MDL Action alleges acts done by BCBS-AZ in the performance of Managed Care Activities,
`
`16
`
`the Claim alleges Related Wrongful Acts to the Love litigation, first made prior to the
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`inception of the Excess Policy, and because the Claim is excluded under Exclusion (B)(1).
`
`Moreover, Allied World has no obligation to pay any amounts under the Excess Policy because
`
`the relief sought by the plaintiffs in the MDL Action does not constitute Loss, is uninsurable as a
`
`matter of law, or is otherwise not covered under the Excess Policy.
`
`WHEREFORE, Allied World prays that the Court declare the rights of the parties and
`
`declare that Allied World has no liability to BCBS-AZ under the Excess Policy for any Loss,
`
`including Defense Expenses, that are the subject of the MDL Action (or the separate actions
`
`consolidated therein) and for such other and further relief as the Court may deem just and
`
`
`
`
`
`
`
`
`
`
`
`15
`
`
`
`

`

`Case 2:21-cv-00938-SMB Document 1 Filed 05/28/21 Page 16 of 16
`
`
`
`
`
`
`TYSON & MENDES, LLP
`
`
`
`
`
`
`
`
`
`
`1
`
`proper.
`
`DATED this 28th day of May, 2021.
`
`TYSON & MENDES, LLP
`
`
`By: /s/ Lynn M. Allen
`Lynn M. Allen
`Attorneys for Plaintiff
`
`
`
`16
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`10
`
`11
`
`12
`
`13
`
`14
`
`15
`
`16
`
`17
`
`18
`
`19
`
`20
`
`21
`
`22
`
`23
`
`24
`
`25
`
`26
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`

This document is available on Docket Alarm but you must sign up to view it.


Or .

Accessing this document will incur an additional charge of $.

After purchase, you can access this document again without charge.

Accept $ Charge
throbber

Still Working On It

This document is taking longer than usual to download. This can happen if we need to contact the court directly to obtain the document and their servers are running slowly.

Give it another minute or two to complete, and then try the refresh button.

throbber

A few More Minutes ... Still Working

It can take up to 5 minutes for us to download a document if the court servers are running slowly.

Thank you for your continued patience.

This document could not be displayed.

We could not find this document within its docket. Please go back to the docket page and check the link. If that does not work, go back to the docket and refresh it to pull the newest information.

Your account does not support viewing this document.

You need a Paid Account to view this document. Click here to change your account type.

Your account does not support viewing this document.

Set your membership status to view this document.

With a Docket Alarm membership, you'll get a whole lot more, including:

  • Up-to-date information for this case.
  • Email alerts whenever there is an update.
  • Full text search for other cases.
  • Get email alerts whenever a new case matches your search.

Become a Member

One Moment Please

The filing “” is large (MB) and is being downloaded.

Please refresh this page in a few minutes to see if the filing has been downloaded. The filing will also be emailed to you when the download completes.

Your document is on its way!

If you do not receive the document in five minutes, contact support at support@docketalarm.com.

Sealed Document

We are unable to display this document, it may be under a court ordered seal.

If you have proper credentials to access the file, you may proceed directly to the court's system using your government issued username and password.


Access Government Site

We are redirecting you
to a mobile optimized page.





Document Unreadable or Corrupt

Refresh this Document
Go to the Docket

We are unable to display this document.

Refresh this Document
Go to the Docket