Lead Opinion
SmileCare Dental Group (“SmileCare”) and Delta Dental Plan of California, Inc. (“Delta Dental”) are dental insurers offering health care plans to employers, labor unions, and individuals. Delta Dental offers a co-payment plan under which it pays participating dentists a portion of their fee and requires them in return to collect the remainder, or co-payment, from their patients at the time of service. SmileCare offers a supplemental plan which provides coverage for the co-payment. Delta Dental does not recognize co-payments made by supplemental in
SmileCare appeals the district court’s dismissal for failure to state a claim, alleging that Delta Dental’s policy violates Section 2 of the Sherman Act, 15 U.S.C. § 2, because it illegitimately restricts competition and is aimed at eliminating SmileCare’s supplemental dental plan. Amici Travelers Insurance Co., Prudential Insurancе Co. of America and Golden Rule Insurance Co. appear in support of Delta Dental. We have jurisdiction pursuant to 28 U.S.C. § 1291, and we affirm.
FACTS AND PROCEDURAL HISTORY
Both parties are dental insurers offering a variety of health care plans to employers, labor unions and individuals. According to SmileCare, sixty percent of all California residents with dental insurance are covered by Delta Dental. Ninety-five percent of California dentists are enrolled, on a nonexclusive basis, as Delta Dental service providers. Delta Dental offers a full coverage plan, but covers most of its insureds through its co-payment plans, which are considerably cheaper. Under the co-payment plan, Delta Dental pays participating dentists a portion of their fee and requires that the dentists recover the remainder directly from the patient as a co-payment. Dentists set their own fees, subject to approval by Delta Dental, and Delta Dental determines the amount of co-payment required according to the type of treatment performed. Deltа Dental’s contract with its service providers prohibits them from waiving the co-payment.
SmileCare offers a variety of dental health plans, but its primary business is a coverage plan called “SmileCare Coverage Plus,” which is designed to supplement co-payment plans such as Delta Dental’s. By paying participating dentists the co-payment, or an agreed-upon portion of the co-payment, Coverage Plus purports to fulfill the patient’s payment obligations to the dentist. Coverage Plus subscribers are thereby provided with full dental coverage. According to SmileCare, Delta Dental has acted to thwart SmileCare and injure the consumer by refusing to accept co-payments from supplemental insurers. Delta Dental providers who accept SmileCare payments in lieu of patient co-payments are deemed by Delta Dental to be in breach of contract, and are allegedly penalized with reduced fee payments, threats of termination, and, in some cases, actual termination.
SmileCare filed its first complaint against Delta Dental on September 8, 1993, alleging a violation of Section 2 of the Sherman Act. The complaint also alleged various causes of action under state law, which, as noted above, are not at issue on appeal. The district court granted Delta Dental’s motion to dismiss with leave to amend. SmileCare’s amended complaint, filed February 25, 1994, alleged virtually the same factual predicate as the first complaint, but also characterized Delta Dental’s conduct as a “group boycott.” On July 25, the district court dismissed SmileCare’s federal claims with prejudice under Fed.R.Civ.P. 12(b)(6). Smilecare Dental Group v. Delta Dental Plan of California,
ANALYSIS
Standard of review.
Dismissal pursuant to Fed.R.Civ.P. 12(b)(6) is reviewed de novo. Everest & Jennings v. American Motorists Ins. Co.,
Whether specific conduct is anti-competitive is a question of law reviewed de novo. Oahu Gas Serv., Inc. v. Pacific Resources, Inc.,
I
Section 2 of the Sherman Act provides: "Every person who shall monopolize, or attempt to monopоlize, or combine or conspire with any other persons, to monopolize any part of the trade or commerce ... shall be deemed guilty of a felony.. . ." 15 U.S.C. § 2. "In order to state a claim for monopolization under Section 2 of the Sherman Act, a plaintiff must prove: (1) Possession of monopoly power in the relevant market; (2) willful acquisition or maintenance of that power; and (3) causal antitrust injury." Pacific Express, Inc. v. United Airlines, Inc.,
The briefs of both parties and amici devote a great deal of space to evaluating the competitive merits of insurance co-payment plans. However, the legality of co-payment plans and waiver prohibition clauses is neither at issue nor seriously in question. In Davidowitz v. Delta Dental Plan of California, Inc.,
Notwithstanding its lengthy forays into the questionable market benefits of insurance co-payment plans, SmileCare repeatedly asserts that it is not challenging Delta Dental's co-payment scheme per sе. Nor is it questioning Delta Dental's right to insist that providers not waive the co-payment. Rather, it is challenging Delta Dental's behavior in refusing to honor supplemental insurers' coverage of the patient's co-payment because it deems such coverage as tantamount to waiver of the co-payment. The key issue, then, is whether Delta Den-
The district court responded to this question after visiting the merits of co-payment plans themselves. Smilecare,
We need not adopt the “moral hazard” theory or reach a conclusion as to the relative market advantage of co-payment plans to decide the instant case. As we stated in Davidowitz, “[we are] not called upon to weigh the wisdom or the public policy of payment assignability. That is the function of Congress. We merely hold the non-assignment clause is legal and is not prohibited by Congress.”
The Kennedy court explained that,
[the defendant insurer’s] policy requirefs] co-payments in order to maintain incentives that hold down the cost of medical care. We could not break the circle in favor of reimbursement without abrogating the co-payment requirеment-a requirement that [defendant] had every legal entitlement to create.... If [a provider] wishes to receive payment under a plan that requires co-payments, then he must collect those co-payments-or at least leave the patient legally responsible for them.
Id. The court added this instructive note: “[Plaintiff] observes that the patient’s rich aunt or best friend may pay the 20% and asks rhetorically: Why can’t the doctor pay? The answer is contractual: Because the plan and policy say that the physiсian must create a legal obligation in the employee or dependent.” Id.
The same reasoning applies here. Delta Dental concedes that if SmileCare paid the patient the co-payment, and the patient then paid the dentist, it would have no objection or cause to find its providers in breach of contract. This would mirror the scenario with the rich aunt. However, because Smile-Care pays the dentist, the legal obligation required of the insured is eliminated, distorting the actuarial basis for Delta Dental’s co-paymеnt plan.
The district court denied as a matter of law SmileCare’s argument that “Delta Dental’s conduct is anticompetitive because it stamps out supplemental plans,” based on its
SmileCare maintains that it is competing with Delta Dental because its supplemental plan threatеns Delta Dental’s business and provides the consumer with a better product at a lower cost. It cites Syufy for the proposition that competition exists where parties impose “an essential discipline [on one another] to provide the consumer with a better product at a lower cost.” United States v. Syufy Enters.,
Instead of competing with Delta Dental directly, SmileCare would “discipline” Delta Dental by encroaching upon its method of disciplining its insureds. We therefore agree with the district court’s conclusion that SmileCare and Dеlta Dental are not true competitors. Rather, SmileCare has found a niche in the coverage “gap” created by Delta Dental’s co-payment plan, and now seeks to impose on Delta Dental its own way of doing business.
Even assuming arguendo that the parties were competitors, SmileCare’s claims that Delta Dental’s conduct amounted to “grouр boycott” or “refusal to deal” in violation of the antitrust laws are not persuasive. SmileCare addressed these claims at greater length before the district court than on appeal. There SmileCare argued that “Delta Dental has used its dominant position in the market to coerce or induce third parties— dentists — to ‘boycott’ SmileCare supplemental coverage patients and plans,”
On appeal, SmileCare cites Klor’s Inc. v. Broadway-Hale Stores, Inc.,
In Aspen, the Supreme Court considered a decision by a ski resort to back out of a ticket-sharing arrangement it had long held with a smaller competitor. The Court held that because the larger resort’s decision “to changе the character of the market” was not based on efficiency or any other legitimate business reason, its conduct was in violation of Section 2 of the Sherman Act.
Furthermore, as the district court observed, it is well-established that eompeti-tors do not have a general duty to deal with one another. Eastman Kodak Co. v. Image Technical Servs., Inc.,
While the existence of valid business reasons is ordinarily a question of fact, in the case before us it is a foregone conclusion requiring no further analysis: The validity of Delta Dental’s business reasons for requiring its dentists to collect the co-payment directly from the patient hаs already been established by our decision in Davidowitz. We therefore agree with the district court that Delta Dental’s policy is supported as a matter of law by a legitimate business justification-its interest in protecting the disciplinary effect of its co-payment plan. Davidowitz,
Because Delta Dental’s co-payment plan is coneededly legitimate, and because Smile-Care has failed to allege that Delta Dental’s enforcement of its no-waiver clause has any anticompetitive effects, we affirm the district court.
AFFIRMED.
Notes
. SmileCare also alleges that Delta Dental’s conduct is in violation of Cal. Health & Safely Code § 1371.2, which provides that health service care providers may not:
reduce the level of payment to a provider based solely on the allegation that the provider has entered into a contract with any other licensed health care service plan for participation in a benefit plan that has been approved by the commissioner.
According to SmileCare, the statute “forbids Delta Dental from reduсing the level of payments to supplemental plan dentists.” Delta Dental responds that its actions were prompted by providers' breach of contract, and not "solely” on their participation in another health care plan. The district court dismissed SmileCare's state law claims, including the statutory claim, without prejudice. The state law claims are not at issue on appeal.
. According to the district court, "Delta Dental concedes that SmileCare has adequately alleged market power." Smilecаre,
. Potential harm to SmileCare alone will not prove Smilecare's case. The courts have reрeatedly observed that "the antitrust laws protect competition, not competitors.” United States v. Syufy Enters.,
. The actuarial basis for Delta Dental’s co-payment plan is premised on the theory that insureds will seek cheaper or less frequent treatment if they are forced to consider the pinch to their own wallets. When SmileCare pays the patient's portion of the fee, the patient has no reason to shop for a less expensive provider or to question the necessity of certain treatments. As the district court observed, "SmileCare and the patient pocket Delta Dental's loss. Of course, this windfall will be short-lived,” for Delta Dental will raise its prices or abandon co-payment plans altogether as unprofitable. Smilecare,
. The court reasoned that moral hazard and antitrust price-fixing рrohibitions require that supplemental and co-payment plans be offered by the same insurer. See Smilecare,
. Although the complaint alleges that SmileCare and Delta Dental are competitors, this is a legal conclusion which we are not bound to accept. Rutman Wine Co. v. E. & J. Gallo Winery,
.The parties also cite Reazin v. Blue Cross & Blue Shield of Kansas, Inc.,
In Reazin, an alleged conspiracy between Blue Cross and two of its participating hospitals to terminate a third hospital's contracting provider agreement and to reduce maximum allowable payments to participating hospitals was deemed an unlawful boycott and refusal to deal. See 899
Despite superficial similarities to the case before us, the cases cited concern substantially different issues. Both Reazin and Ocean State involve the propriety of mechanisms designed to control health care costs directly through price agreements (sometimes called “Most Favored Nation” clauses) between insurers and providers. Here, the clause in question is not a price-setting arrangement, but what might be termed a patient-control mechanism. That is to say, the no-waiver provision is designed to control costs by making patients conscious of the price of dental care. It does not control the price of dental services, but rather the frequency with which they are used. Because we find the clause in question significantly different than the ones at issue in the cases сited, we do not consider them in reaching our decision.
Dissenting Opinion
dissenting:
Because I believe that certain acts allegedly committed by Delta Dental, if proved, could constitute anticompetitive and predatory conduct within the meaning of the antitrust laws, I dissent.
The majority opinion holds that Delta’s conduct forcing SmileCare and other supplemental plans out of the dental insurance market cannot be interpreted as anticompeti-tive because Delta and SmileCare are not true competitors and becаuse the business policy by which Delta justifies its allegedly anticompetitive conduct is legitimate. Based on the procedural posture of this appeal, I disagree.
On a motion to dismiss for failure to state a claim under Fed.R.Civ.P. 12(b)(6), facts alleged by the nonmoving party are presumed to be true. Everest & Jennings v. American Motorists Ins. Co.,
Both the district court’s finding and the majority opinion’s conclusion that Delta Dental’s policy results in no impermissible anti-competitive effects rest on eases interpreting ERISA rather than the Sherman Act. See maj. op. at 784, 785; Smilecare,
To decide whether Delta and SmileCare are competitors, the district court must first conduct a factual inquiry into the definition of the relevant market. See Thurman Industries, Inc. v. Pay ‘N Pak Stores, Inc.,
The majority opinion then states that, assuming Delta and SmileCare were competitors, the key question is whether Delta’s refusal to accept SmileCare supplemental payments in lieu of patients’ co-payments has anticompetitive effects. The majority opinion holds that Delta’s conduct is not anticom-petitive bеcause Delta has a legitimate business justification for its refusal to accept SmileCare’s supplemental payments. This misguided analysis, however, puts the cart before the horse.
A business justification is a defense to allegations of anticompetitive conduct. Phonetele, Inc. v. American Tel. and Tel.,
In deciding this issue, what the district court has really done is to ignore the rule that on a motion to dismiss facts alleged by the nonmoving party are presumed true.
Because SmileCare has alleged facts which, if proved, could entitle it to relief under the antitrust laws, see Conley v. Gibson,
