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Villazon v. Prudential Health Care Plan3/27/2003
ll the circumstances of their dealings with each other. Cantor v. Cochran, 184 So. 2d 173, 174 (Fla. 1966); see also Parker v. Domino's Pizza, Inc., 629 So. 2d 1026, 1027 (Fla. 4th DCA 1993) (holding that the nature and extent of the relationship of parties with regard to agency presents a question of fact and is not controlled by descriptive labels employed by the parties); Nazworth, 486 So. 2d at 638 (recognizing that the use of descriptive labels in a contract is not determinative of the actual legal relationship between parties). The physician's contractual independent contractor status does not alone preclude a finding of agency.
Here, the record evidence reflects significant indicia of PruCare's right to control the means by which medical services were rendered by Member Physicians to Member Patients. The facts peculiar to each case must govern the ultimate disposition. While physicians of the past in the traditional pattern of American life may have constituted distinct independent entities and independent centers of occupation and profession, that model has been dramatically altered through the HMO concept in a significant manner which a legal system cannot simply ignore. The thought of visiting a private and independent office of a totally independent physician may now be one more of history and cultural conditioning than current reality. The economic structures alone may so impact the relationships that the prism through which we consider and evaluate issues of control must be honed for this current reality.
On deposition, the PruCare representative, Dominick Messano, testified regarding PruCare's relationship with the HMO network physicians. Consistent with the Certificate of Coverage, Messano indicated that PruCare determines which providers are part of the HMO network, and that HMO patient members are required to use HMO network physicians. Significantly, the Certificate of Coverage contains provisions which demonstrate PruCare's right to control important aspects of patient care provided by the HMO.
In Part I (explaining the scope of Group Health Care Coverage), the Certificate provides that PruCare "will arrange or provide for benefits for the Eligible Services and Supplies" set forth in the Certificate of Coverage. All Eligible Services and Supplies must be furnished by a Primary Care Physician, another Participating Health Care Provider authorized by a Primary Care Physician, or a Non-Participating Health Care Provider authorized by a Primary Care Physician. "In addition, certain services and supplies" (such as infertility services or counseling services upon the death of a terminally ill covered person) "must be authorized by the Medical Director to be eligible."
Further, the definitions section contains these operative provisions:
(1) Covered Persons may be referred to Consulting Physicians only if "referred for care in writing by a Participating Physician," and only if such "services have been approved, in advance, by the Medical Director and confirmed in writing by the Medical Director."
(2) A "Medical Director" is defined as a "Physician who is a consultant retained by PruCare to coordinate and supervise the delivery of health care services for Covered Persons through Participating Physicians and Participating Health Care Providers."
(3) A "Participating Health Care Provider" is defined as a "Physician, Hospital or other provider of medical services or supplies which is licensed or certified in the state in which it is located and which has agreed with PruCare, directly or indirectly, to arrange or provide for furnishing services and supplies for medical care and treatment to Covered Persons."
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