BRENT ADAMS and PATRICIA E.G. ADAMS, Plaintiffs-Appellants,
HAWAII MEDICAL SERVICE ASSOCIATION, Defendant-Appellee, and JOHN DOES 1-99; JANE DOES 1-99; DOE ENTITIES 1-20; and DOE GOVERNMENTAL UNITS 1-20, Defendants
NOT FOR PUBLICATION IN WEST'S HAWAI'I REPORTS AND PACIFIC REPORTER
APPEAL FROM THE CIRCUIT COURT OF THE FIRST CIRCUIT (CIVIL NO. 07-1-1388)
Arleen D. Jouxson and Rafael G. Del Castillo, for Plaintiffs-Appellants.
Dianne Winter Brookins and Jason H. Kim (Alston Hunt Floyd & Ing), for Defendant-Appellee.
Fujise, Presiding Judge, Leonard and Ginoza, JJ.
SUMMARY DISPOSITION ORDER
Plaintiffs-Appellants Brent Adams (now deceased) and Patricia E.G. Adams (collectively, the Adamses) appeal from a December 28, 2009 Judgment entered by the Circuit Court of the First Circuit (Circuit Court) in favor of Defendant-Appellee Hawaii Medical Service Association (HMSA) and against the Adamses. This case is related to this court's prior decision in Hawai'i Medical Service Ass'n v. Adams, 120 Hawai'i 446, 209 P.3d 1260 (App. 2009) (Adams I) in which this court held that HMSA properly denied authorization in 2007 for the same medical procedure requested by the same parties in 2006.
The Adamses raise three points on appeal. They challenge the Circuit Court's "dismissal" of their complaint for
(1) Breach of contract and bad faith arising from HMSA's denial of the 2006 request for an allo-transplant
because the Commissioner in Adams I reversed HMSA's 2007 denial . . . not its 2006 denial, which was never submitted to his external review process. Thus, HMSA's appeal in Adams I did not concern its 2006 breach of the contractual and statutory requirement to apply the medical necessity criteria where the denial is based on medical necessity, and bad faith conduct, which remain the subject of the Complaint.
(2) Bad faith based on HMSA's "refusal to reconsider its denial because HMSA did not appeal from the [insurance commissioner's] conclusion it constituted bad faith, and thus it was not an issue this Court in Adams I held was moot."
(3) Negligent infliction of emotional distress (NIED) and intentional infliction of emotional distress (IIED)
based on HMSA's 2006 conduct as those claims were sufficiently pleaded in the Complaint and were independent of whether the allogeneic transplant was ultimately determined to be specifically excluded as that was not the basis for HMSA's conduct, and because Adams I concerned HMSA's 2007 denial, not its 2006 tortious conduct in 2006, which was adequately pleaded in the Complaint.
After a careful review of the issues raised and arguments made by the parties, the record, and the applicable authority, we resolve the Adamses' points as follows.
With regard to the first point on appeal, the Circuit Court did not err in granting summary judgment on the Adamses' claim for breach of contract for the 2006 denial of their request for pre-authorization of an allogeneic stem-cell transplant (allo-transplant). Our decision in Adams I held that the Preferred Provider Plan for the Hawai'i Employer-Union Health Benefits Trust Fund (the Plan) specifically excluded allo-transplants from its coverage. As the Plan also ...