D. McGrody v. PA Health Ins. Exchange Auth. d/b/a Pennie
1051 C.D. 2023
| Pa. Commw. Ct. | Oct 11, 2024Background
- Deborah McGrody appealed to Pennie, Pennsylvania’s state health insurance exchange, after being billed for health insurance coverage for October 2021 despite terminating her policy on October 1, 2021, upon securing alternate coverage.
- McGrody claimed she was not informed by the Pennie representative that her termination would be effective at the end of October rather than retroactively to September 30, and that she would owe a premium for October.
- McGrody received notice of the outstanding bill only in April 2023 through a collection letter, then filed an appeal in July 2023.
- Pennie moved to dismiss the appeal, arguing that (1) the appeal was untimely (outside the 90-day window) and (2) federal regulations did not permit appeals of termination dates or retroactive termination in McGrody’s circumstances.
- The Presiding Officer dismissed the appeal, finding McGrody’s situation did not fit any exception for retroactive coverage termination under 45 C.F.R. § 155.430(b) and that her appeal was outside allowed grounds.
- McGrody sought judicial review; the Commonwealth Court upheld the dismissal.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Right to appeal coverage termination date | McGrody should be able to appeal because she was not advised of retroactive options or the bill | Pennie argued appeals are limited to eligibility determinations; termination dates are not appealable | Appeal not permitted for termination dates |
| Timeliness of appeal | McGrody did not know about the bill until April 2023; appeal should be allowed | Appeal filed well after 90-day deadline; no exceptional circumstance found | Appeal untimely; no exceptional circumstance |
| Eligibility for retroactive termination | McGrody relied on Pennie rep's guidance, was not told about retroactive option | Retroactive termination allowed only for technical error, misconduct, or lack of consent | No retroactive termination warranted |
| Adequacy of notice from Pennie | Representative failed to inform about continued obligation or retroactive option | Rep explained coverage would continue until end of October; no exceptional case | No violation by Pennie; no relief for McGrody |
Key Cases Cited
- Meyer v. Cmty. Coll. of Beaver Cnty., 93 A.3d 806 (Pa. 2014) (standard of review for questions of law is de novo)
- Dechert LLP v. Commonwealth, 998 A.2d 575 (Pa. 2010) (scope of review in appeals from administrative agencies)
- Mercury Trucking, Inc. v. Pa. Pub. Util. Comm’n, 55 A.3d 1056 (Pa. 2012) (plenary review applies to questions of law in administrative appeals)
- Lyness v. State Bd. of Med., 605 A.2d 1204 (Pa. 1992) (requirement for separation of adjudicatory and prosecutorial functions in agency proceedings)