Spectera, Inc. v. Wilson

• Decision Date: 07 October 2013
• Docket Number: No. S12G1935.,S12G1935.
• Parties: SPECTERA, INC. v. WILSON et al.
• Court: Georgia Supreme Court

294 Ga. 23

749 S.E.2d 704

SPECTERA, INC.

v.WILSON et al.

No. S12G1935.

Supreme Court of Georgia.

Oct. 7, 2013.

Michael J. Bowers, Malissa Anne Kaufold–Wiggins, Atlanta, Cavender Chris Kimble, Birmingham, Balch & Bingham LLP, Wade P.K. Carr, Bruce E. Baty, Kansas City, Eric Justin Andalman, Chicago, Dentons US LLP, for appellant.

Walter Gus Elliott, II, Elliott, Blackburn & Gooding, P.C., Valdosta, for Appellee.

Aubrey T. Villines, Jr., Atlanta, Jeffrey Robert Filipovits, Filipovits Law Firm, P.C., Atlanta, for Amicus appellee.

BENHAM, Justice.

This appeal is from the grant of a petition for a writ of certiorari from a decision issued by the Court of Appeals in Spectera, Inc. v. Wilson, 317 Ga.App. 64, 730 S.E.2d 699 (2012). The record shows that appellant Spectera is a vision care insurer providing eye care benefits coverage to Georgia residents. To provide eye care coverage for its insureds, Spectera contracts with different types of vision care providers including independent participating providers and retail chain providers. Appellee Steven M. Wilson is a licensed optometrist employed by Steven M. Wilson, O.D., P.C., providing eye care services in Lowndes County as Wilson Eye Center (“WEC”). Appellees Cynthia McMurray, Jodie E. Summers, and David Price are also licensed optometrists employed by WEC. Prior to 2010, Spectera had entered provider contracts known as “Patriot contracts” with Wilson and McMurray and they became members of Spectera's panel of eye care providers. Summers likewise was on Spectera's panel of eye care providers. Under the Patriot contract, independent participating providers such as appellees could use their own materials (lenses, frames, contacts) or materials obtained from any other source to service Spectera insureds who came to them for their eye care needs. Appellees' business practice was to keep an inventory of materials that it obtained from third parties. Under the Patriot contract, Spectera would reimburse appellees for the materials Spectera insureds used from WEC's inventory by paying appellees a fee for their materials' costs and by having Spectera insureds remit a materials co-payment to appellees. See Spectera, Inc. v. Wilson, supra, 317 Ga.App. at 68, 730 S.E.2d 699.

In 2010, Spectera decided to terminate its Patriot contracts and replace them with independent participating provider (IPP) agreements. Spectera's IPP agreement describes “Covered Vision Services” as follows:

The Provider shall provide a professional comprehensive eye examination, including tonometry, when indicated. The Provider shall provide professional and courteous dispensing and fitting of eyeglasses and/or contact lenses to Patients. When the use of a laboratory is required to provide services or products to Enrollees, the Provider agrees to use [Spectera's optical laboratory].¹ (Emphasis supplied.)

According to the affidavit of Lori Archer, Spectera's Senior Vice President of Provider Network Solutions, this portion of the IPP agreement (the “covered materials requirement”) means independent participating providerslike appellees would be required to obtain covered materials (lenses, frames, and “formulary contact lenses”) from Spectera when servicing Spectera insureds. Under this agreement, Archer states the only materials independent participating providers like appellees may provide to Spectera insureds, regardless of the source of the materials, would be non-covered materials such as prescription sunglasses or spare pairs of eyeglasses. In addition, Spectera admitted in its court filings that under the IPP agreement “[appellees] would no longer receive the reimbursement for materials from Spectera and would no longer be entitled to retain the materials co[-]pays from Spectera insureds.” Spectera maintains the IPP agreement is more cost-effective for its insureds who seek eye care from independent eye care providers. In contrast to its IPP agreements with independent participating providers, Spectera does not impose a covered materials requirement in its contracts with the retail chain providers (i.e., Walmart). Thus, retail chain providers which service Spectera insureds may source their materials from any laboratory of their choosing and prepare those materials directly for Spectera insureds.

Appellees sued Spectera contending that Spectera's proposed IPP agreement violated various subsections of Georgia's Patient Access to Eye Care Act, OCGA § 33–24–59.12 (the “Act”). While the case was pending, the trial court issued a temporary injunction prohibiting Spectera from forcing its panel of independent participating providers in Georgia to abide by the IPP agreement. After the trial court temporarily enjoined Spectera from enforcing its IPP agreement, Spectera sought to remove appellees Wilson, Summers, and McMurray from its approved panel of providers altogether; but the trial court enjoined Spectera from taking such action. Although appellee Price was not on Spectera's provider panel, he alleged Spectera violated the Act by denying him membership on its panel because of his refusal to sign the IPP agreement. Upon considering the parties' cross motions for summary judgment, the trial court granted the appellees' motions for summary judgment, denied Spectera's motion for summary judgment and issued a permanent injunction precluding Spectera from enforcing the restrictions contained in the IPP agreement as to “ any other licensed eye care provider on [Spectera's] provider panel” or those who had applied for admittance to the panel. The trial court later modified its injunction by suspending it “as to eye care providers other than [appellees] pending a final determination on appeal.”

Spectera appealed the trial court's decision to the Court of Appeals which affirmed in part and reversed in part. The Court of Appeals found that the covered materials requirement in the IPP agreement violated subsections (c)(2) ² and (c)(5) ³ of the Act in regard to independent optometrists and so it affirmed appellees' motions for summary judgment in regard to those subsections of the Act. Spectera, Inc. v. Wilson, supra, 317 Ga.App. at 69, 73, 730 S.E.2d 699. The Court of Appeals found no violation of subsection (c)(3) ⁴ and so it reversed the trial court's grant of summary judgment to the appellees in regard to that subsection. Id. at 73, 730 S.E.2d 699. As to subsection (c)(6) ⁵of the Act, the Court of Appeals determined Spectera violated that subsection because it “unlawfully utilized an improper condition to exclude [appellee Price] from his initial admittance to the Panel,” ( id. at 74, 730 S.E.2d 699), and so it affirmed the grant of summary judgment to Price. Finally, the Court of Appeals limited the award of injunctive relief to independent optometrists. We granted Spectera's petition for a writ of certiorari and requested that the parties respond to the following question: “Did the Court of Appeals correctly construe OCGA § 33–24–59.12(c) of the Patient Access to Eye Care Act?” For the reasons below, we affirm in part, reverse in part, and vacate in part.

1. Spectera contends the Court of Appeals erred when it construed subsections (c)(2), (c)(3), and (c)(5) of the Act. We discuss Spectera's allegations regarding these subsections in turn.

(a) Spectera contends that its IPP agreement does not violate subsection (c)(2) of the Act. That subsection provides that an insurer “shall ... [n]ot preclude a covered person who seeks eye care from obtaining such service directly from a provider on the health benefit provider panel who is licensed to provide eye care.” Spectera argues the Court of Appeals erred when it found that the IPP agreement's covered materials requirement effectively required Spectera insureds to purchase their materials directly from Spectera. See Spectera v. Wilson, supra, 317 Ga.App. at 68, 730 S.E.2d 699. According to Spectera, the use of the word “directly” in subsection (c)(2) is indicative of the legislature's intent to eliminate the requirement of a physician referral prior to obtaining eye care. Spectera claims its insureds receive their eye care directly from their providers because the providers still dispense the assembled materials (i.e., eyeglasses) which the provider has obtained from Spectera. Spectera further opines that independent participating providers like appellees are not the “covered person[s]” whom the statute protects.

“It is elementary that in all interpretations of statutes, the courts shall look diligently for the intention of the General Assembly. In so doing, the ordinary signification shall be applied to all words. Where the language of a statute is plain and susceptible to only one natural and reasonable construction, courts must construe the statute accordingly. In fact, where the language of a statute is plain and unambiguous, judicial construction is not only unnecessary but forbidden.” Chase v. State, 285 Ga. 693, 695(2), 681 S.E.2d 116 (2009) (citation and punctuation omitted). Here, Spectera's arguments are inconsistent with the plain language of the statute. While it is true that the requirement of a physician referral would likely be prohibited by subsection (c)(2), the statute is not limited only to that particular circumstance. The statute says the insurer shall not preclude an insured from seeking eye care directly from his eye care provider. “Eye care” is defined by the Act as “those healthcare services and materials related to the care of the eye and related structures and vision care services which an insurer is obligated to pay for or provide to covered persons under the health benefit plan.” OCGA § 33–24–59.12(b)(3) (emphasis supplied). In addition, the practice of optometry consists of the correction of visual anomalies through the “... use of lenses, prisms, frames, mountings, contact lenses, ... and any other means or methods for the relief, correction, or remedy of any insufficiencies or abnormal conditions of the human...