|
|
|
| |
case
histories |
DAVID
SINTEK, DDS v.
THE PRUDENTIAL INSURANCE COMPANY OF AMERICA, et al. |
| |
| |
|
|
Settlement
Amount:
$3,500,000 settlement fund (plus attorneys' fees and costs) |
| |
|
|
|
| |
|
|
Case
Name:
DAVID SINTEK, DDS v. THE PRUDENTIAL INSURANCE COMPANY OF AMERICA,
et al. |
| |
|
|
|
| |
|
|
Case
Number:
San Diego County Superior Court Case No. 717345 |
| |
|
|
|
| |
|
|
Plaintiff:
Nationwide Class Action - approximately 2,000 dentists |
| |
|
|
|
| |
|
|
Defendants:
The Prudential Insurance Company of America
Prudential Health Care Plan of California, Inc.
Prudential Health Care Plan of Georgia, Inc.
Prudential Dental Maintenance Organization, Inc. (Texas) |
| |
|
|
|
| |
|
|
Facts
and Background:
In 1985 Prudential Insurance Company of America ("Prudential")
began to market the dental equivalent of a HMO (health maintenance
organization) by offering the "Prudential Insurance Company
of America Dental Maintenance Organization" ("DMO")
plan. While many HMOs provide dental insurance, the Prudential
DMO plan was designed exclusively to provide dental insurance.
Not unlike a traditional HMO, Prudential sold its group DMO
coverage to subscriber companies or groups. Employees of those
groups would become "Covered Members" by electing
coverage for themselves and their dependents and selecting a
primary care dentist, i.e., a Personal Dentist. The DMO would
then provide prepaid dental care to its covered members by contracting
with providers of dental services, i.e., dentists throughout
the country, and by placing the covered members on the rosters
of the
dentists.
The dentist providers were to be compensated under one of four
different methods of payment, including capitation, whereby
the dentist received a monthly payment for each covered patient
on his or her roster, regardless of whether any dental care
was
actually delivered during that month to such patients.
Since the amount of capitation to be paid on a monthly basis
by Prudential to each participating dentist was calculated by
Prudential based on the number of covered members whose names
appeared on the dentist's roster (i.e., employees of companies
which subscribed to the Prudential DMO plan and spouses and
dependents of those employees who elected coverage and had selected
a particular dentist), it was essential that Prudential ensure
that all covered members who had selected a dental provider
were listed on that dentist's roster (and were listed timely),
so that capitation would be paid to the dentist for those covered
members. |
| |
|
|
|
| |
|
|
Plaintiff's
Contentions:
Plaintiff alleged that for the first ten years of operation
of its DMO, Prudential did not pay the dental providers capitation
for children under the age of three, even though Prudential
had been provided with information (by way of enrollment applications)
by the members of the Plan (employees of the subscriber to the
Plan) designating the particular dentist as a "Personal
Dentist," i.e., dental provider, for the employee and
specified dependents of the member/employee, including children
under the age of three.
Plaintiff alleged that from 1985 to 1995, as a matter of corporate
policy, Prudential ordinarily did not include children under
the age of three on the patient roster list provided to dentists
and failed to pay capitation to the dentists for these covered
members. At some point in the latter half of 1994, this issue
of non-payment of capitation on children under the age of three
became a significant issue. Plaintiff alleged Prudential made
the decision that commencing in January 1995 it would ensure
that compensation was paid to the dental providers for these
covered persons under the age of three. However, Prudential
made the decision not to pay any compensation to the dentists
from whom these capitation payments had been wrongfully withheld
since 1985. |
| |
|
|
|
| |
|
|
Defendants'
Contentions:
Defendants denied deny each and all of the claims and contentions
alleged by Dr. Sintek in the Litigation. Defendants denied all
charges of wrongdoing or liability against them arising out
of any of the conduct, statements, acts or omissions alleged,
or that could have been alleged, in the Litigation. Defendants
also denied that Plaintiff or the Class suffered damages or
were harmed by the conduct alleged in the Litigation. |
| |
|
|
|
| |
|
|
Damages:
Non-payment of capitation to dentists nationwide over 10 year
period. |
|
|
|
|
