Administrator Hired to Run City's Health Insurance Program Owes Duty of Good Faith and Fair Dealing Just as Insurer Would Owe Duty
科罗拉多州最高法院裁定，第三方医保计划管理员即使与参保人无直接合同关系，也可能因管理不善被起诉违约或恶意拒赔，这对参保人维权和保险公司责任界定有重要参考。
Cary v. United of Omaha Life Insurance Co., 68 P.3d 462 (Supreme Court of Colorado--April 21, 2003) The city of Arvada, Colorado, provided a self-funded health insurance program to its employees through the Arvada Medical and Disability Program Trust Fund. The Trust was administered by United of Omaha and Mutual of Omaha of Colorado. Under the arrangement, the Trust was governed by a Board of Trustees but had no employee staff of its own. Rather, the Trust relied on United and Mutual for claims administration. The Trust's arrangement with United was akin to stop-loss insurance for the Trust in that the Trust was responsible for the first $75,000 of covered payments for employee illness, with United responsible for amounts between $75,000 and $1 million. The daughter of Plan member Cary shot herself in an unsuccessful suicide attempt, leading to extensive injuries and extensive, expensive medical treatment. United, acting as administrator for the Trust, refused coverage, citing the Plan's exclusion of self-inflicted injuries. Cary sued for benefits and alleged bad faith in the denial. The trial court granted partial summary judgment for Cary, finding that the exclusion for self-inflicted injury was ambiguous. Applying the rule of construing ambiguities against the drafter, the trial court ruled for Cary and against the Plan on the coverage issue. However, the trial court also dismissed the bad faith claim on the ground that United as Plan administrator was not in contractual privity with Cary and hence could not be sued for bad faith. According to the trial court, the insurance contract was only between the Plan and Cary. Therefore, according to the trial court, Cary had no to sue United for contract-based claims since Cary had not directly contracted with United. The intermediate state court of appeals affirmed the trial court's decisions. The Colorado Supreme Court reversed the lower courts and held that United, although a third-party insurance plan administrator technically outside the contractual relationship between Cary and the Trust, was nonetheless a proper defendant for claims arising out of United's administration of the Trust. The Supreme Court reasoned that United as administrator effectively took the role of the Trust in determining claims payment and treatment of the insured. Consequently, United as administrator should be responsible for any bad faith or other misconduct that adversely affects the insured. Note that the Cary v. United of Omaha decision does not state that United acted in bad faith by invoking the self-inflicted wound exclusion and denying the Cary claim. The actual merits of the Cary bad faith claim against United will be determined by the trial court, which now has the matter again after the Supreme Court's remand of the case. The Cary v. United decision merely states that Cary has the legal right to sue United for bad faith. Proving it may be quite another thing because characterizing attempted suicide as a self-inflicted injury may well be seen as reasonable conduct by United even if the trial court disagreed as to the clarity of the exclusion and its ultimate impact on coverage. The test for determining bad faith in Colorado and most states devolves largely to a question of whether an insurer's conduct was reasonable, not whether it was completely correct. United would, of course, prefer not to be sued at all. However, United will not be found liable merely because it was wrong at the end of the day. This notion that one had contract rights only against the entity with which it directly contracts is contractual privity or primary contractual relationship. Historically, under the common law, only parties in direct contractual relationships could sue one another over disputes related to the contract. Although others might well be affected by the contract, they did not have the required legal standing to sue for rights under the contract. …