Community Hospital of the Monterey Peninsula v. Aetna Life Insurance
Community Hospital of the Monterey Peninsula v. Aetna Life Insurance
Opinion of the Court
ORDER GRANTING-IN-PART DEFENDANT’S MOTION FOR PARTIAL SUMMARY JUDGMENT
Two years ago, a patient insured by Defendant Aetna Life Insurance Company sought treatment on three separate occasions from Plaintiff Community Hospital of the Monterey Peninsula. Aetna verified that the patient was eligible for coverage, but refused CHOMP’s demand that it pay 100 percent of the charges billed.
I.
Pursuant to Fed.R.Civ.P. 56(a), summary judgment is appropriate when “there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.” Material facts are those that may affect the outcome of the case.
CHOMP is a health care provider doing business primarily in Monterey County, California. Aetna provides and administers health care benefits plans to members. CHOMP and Aetna “had a preferred provider agreement in place until 2011 which called for payment by [Aetna] of 100% of the billed charges for services provided to its members. [Biit] that agreement expired on January 1, 2011.”
As to the first visit in February 2013, CHOMP admitted the patient to its emergency room for “severe diabetic ketoacido-sis.” CHOMP promptly contacted Aetna for authorization to treat the patient, and Aetna verified the patient’s insurance eligibility.
As to the second visit in July 2013, CHOMP re-admitted the patient to its emergency room-for the same;medical condition.
As to the third visit in September 2013, CHOMP admitted the patient to its emergency room for diabetic ketoacidosis yet again.
II.
This court has jurisdiction under 28 U.S.C. § 1332. The parties further consent to the jurisdiction- of the undersigned under 28 U.S.C. § 636(c) and Fed.R.Civ.P. 72(a).
III.
At this stage of the case, a court “does not assess credibility or weigh the evidence, but simply determines whether there is a genuine factual issue for trial.”
First, no reasonable jury could find that Aetna is liable for negligent misrepresentation based on the July visit. “The elements of negligent misrepresentation are (1) a misrepresentation of a past or existing material fact, (2) made without reasonable ground for believing it to be true, (3) made with the-intent to induce another’s reliance on the fact misrepresented, (4) justifiable reliance on the misrepresentation, and (5). resulting damage.”
The suggestion that Aetna’s authorization constitutes a misrepresentation also fails as a matter of law. CHOMP argues that the “authorizations associated with [the patient’s July visit] came in advance of treatment and induced the Hospital to act, thereby forming a basis for the Hospital’s negligent misrepresentation claim.”
Second, no reasonable jury could find that Aetna breached any implied contract. To prevail on a breach of contract claim, CHOMP must show (1) “existence of the contract,” (2) “performance by the plaintiff or excuse for nonperformance,” (3) “breach by the defendant” and (4) “damages.”
But the dispositive issue here is not whether there was a contract in place, but whether there is any genuine issue that full payment was expected under the contract. CHOMP contends that “Aetna’s verifications of Patient’s benefits and authorization of services amounted to a mutual agreement that [CHOMP] would provide the health care services to Patient as medically necessary, and, in exchange, Aetna would pay [CHOMP] for all billed charges incurred in such care and treatment.”
The UCL prohibits “any unlawful, unfair or fraudulent business act or practice.”
CHOMP alleges that “Aetna’s rescission of the verifications of benefits and authorizations of treatment subsequent to [CHOMP’s] provision of health care service to Patient” violated Cal. Health & Safety Code § 1371.8 and Cal. Ins.Code § 796.04 and that this conduct “constitute[d] an unfair business practice in violation of’ Cal. Bus. & Prof.Code § 17200.
Fourth, CHOMP’s claim for common count-services rendered based on the July visit cannot survive summary judgment because no reasonable jury could conclude that Aetna requested CHOMP’s services. “A common count is not a specific cause of action ... rather, it is a simplified form of- pleading normally used to aver the existence of various forms of monetary indebtedness.”
Fifth, CHOMP’s claim for common count-open book account presents a question of disputed fact for the jury.
IY.
The motion for summary judgment is GRANTED-IN-PART. .
SO ORDERED.
. See Docket No. 1, Exh. A at ¶¶ 21-60.
. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986) (“Only disputes over facts that may affect the outcome of the suit under governing law will properly preclude the entry of summary judgment. Factual disputes that are irrelevant or unnecessary will not be counted.”).
. See id.
. Docket No. 36 at ¶ 3.
. Docket No. 29-1 at ¶ 3.
. Id. at ¶ 20.
. See id. at ¶¶ 4, 5.
. See id. at ¶ 5.
.Id. at ¶ 6. "The process of daily telephone communication between a hospital and a health plan regarding ongoing patient treatment is known in the healthcare industry as 'utilization review.’ The purpose of the utilization review process is to ensure that medical providers and health plans agree on the medical necessity of services being provided. Providers regularly rely on the authorizations provided through the utilization review process,- in conjunction with separate verifications of patients’ benefits, as representations that health plans will pay for the authorized services subject only to lawful exclusions.” Docket No. 36 at ¶ 12.
.Docket No. 34 at 2.
. Id. (internal footnote omitted).
. See Docket No. 1, Exh. A at ¶ 9.
. Id. at ¶ 10.
. See Docket No. 34 at 3,
. The distinction between in-netwórk and out-of-network providers is relevant to a given insurer's reimbursement rate.
. Docket No. 29 at 5,
. Docket No. 36 at Exh. H, See also Docket No. 37 at ¶ 5; Docket No. 34 at 3.
.' Id.
. See id.
. Id. The disclaimer language states: “Except for services considered to be an emergency, if the health benefit plan includes an out-of-network benefit component for the use of a non-participating provider, claims received for eligible services may be processed at the out-of-network or non-preferred benefit level. Members may be responsible for higher copayments, deductibles, and coinsurance, plus any charges by the provider in excess of the amounts covered by the plan for services provided by out-of-network provider. These excess amounts may be significant.” Docket No. 36 at Exh. I.
. Docket No. 34 at 4.
. Id.
. See Docket No. 1, Exh. A at ¶ 14.
. Id. at ¶ 15.
. See id.
. Id. at ¶ 16.
. Docket No. 34 at 4.
. Id.
. See Docket No. 1, Exh. A at ¶¶ 21-60.
. See Docket No. 29 at 1.
. See Docket No. 34.
. See Cal. Bus. & Prof.Code § 17200. CHOMP asserts two separate UCL claims. First, CHOMP alleges that Aetna violated Cal. Health & Safely Code § 1371.8 (addressing rescission or modification of' authorizations by a health care service plan) and Cal. Ins. Code § 796.04 (same). Second, CHOMP alleges that Aetna is "required to pay ... for the emergency services provided to its members without requiring prior authorization, pursuant to the public policy favoring patient access to health Care, -as stated in’' Cal. Health & Safety Code §§ 1317, 1371 and Cal. Ins.Code § 10133. See Docket No. 1, Exh. A at n 39-43.
. See Docket No. 34 at 6-10. Aetna does not seek summary judgment on CHOMP’s sixth cause of action for quantum meruit, acknowledging that there are triable issues of fact based on all three visits. See Docket No. 29 at 1 n.l.
. House v. Bell, 547 U.S. 518, 559-60, 126 S.Ct. 2064, 165 L.Ed.2d 1 (2006).
. See Celotex Corp. v. Catrett, 477 U.S. 317, 323-24, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986).
. See T.W. Elec. Serv., Inc. v. Pac. Elec. Contractors Ass’n, 809 F.2d 626, 630 (9th Cir. 1987).
. Ragland v. U.S. Bank Nat'l Ass’n, 209 Cal. App. 4th 182, 196, 147 Cal.Rptr.3d 41 (2012) (citing Wells Fargo Bank, N.A. v. FSI, Fin. Sols., Inc., 1-96 Cal.App.4th 1559, 1573, 127 Cal.Rptr.3d 589 (2011); Nat'l Union Fire Ins. Co. of Pittsburgh, Pa. v. Cambridge Integrated Servs. Grp., Inc., 171 Cal.App.4th 35, 50, 89 Cal.Rptr.3d 473 (2009)).
. See, e.g., Melican v. Regents of the Univ. of Cal., 151 Cal.App.4th 168, 182, 59 Cal.
. Docket No. 1, Exh. A at 1[¶ 23-27.
. Docket No. 29 at 4:11-12.
. Docket No. 34 at 6 n.2.
. Id. at 6.
. See id. at 6-7. CHOMP’s reliance on Enloe Med. Ctr. v. Principal Life Ins. Co. to support its claim for negligent misrepresentation is misplaced. Case No. 10-cv-02227, 2011 WL 6396517, at *5-7 (E.D.Cal. Dec. 20, 2011). CHOMP’s reference to Enloe focuses on the court’s conclusion that "in some instances, a contract may be created on an authorization call.” Id. at *6. The court reached that conclusion during its discussion of whether or not an implied-in-fact contract had been formed. Id. at *5-7. When analyzing the plaintiff’s negligent misrepresentation claim, the court noted that the "claim [was] grounded in the same underlying facts as the claim for an implied in fact contract.” Id. at *7. Because it was not presented with sufficient facts, the court denied the defendant's motion for summary judgment of negligent misrepresentation. Id.
. See Ragland, 209 Cal.App.4th at 196, 147 Cal.Rptr.3d 41.
. Regents of the Univ. of Cal. v. Principal Fin. Grp., 412 F.Supp.2d 1037, 1045 (N.D.Cal. 2006); see also Tenet Healthsystem Desert, Inc. v. Fords Ins. Co., Inc., 520 F.Supp.2d 1184, 1195 (C.D.Cal. 2007). Additionally, any attempt by CHOMP to hang its negligent misrepresentation claim on the fact’ that Aetna’s alleged verbal authorizations did not contain disclaimer language would be insufficient. See Docket No. 34 at 3; see Principal Fin. Grp., 412 F.Supp.2d at 1045 (“California negligent misrepresentation law ... does not impose liability for negligent omissions; some 'positive assertion’ is required.”); see also Tenet Healthsystem Desert, Inc., 520 F.Supp.2d at 1195.
. First Commercial Mortg. Co. v. Reece, 89 Cal.App.4th 731, 745, 108 Cal.Rptr.2d 23 (2001); see also Acoustics, Inc. v. Trepte Constr. Co., 14 Cal.App.3d 887, 913, 92 Cal. Rptr. 723 (1971).
. Enloe Med. Ctr., 2011 WL 6396517, at *5 (quoting Cal. Civ.Code § 1621) (internal quotations omitted).
. Id. at *5 (citing Kashmiri v. Regents of the Univ. of Cal., 156 Cal.App.4th 809, 829, 67 Cal.Rptr.3d 635 (2007)).
. See Docket No. 37 at ¶¶ 2-4; Docket No. 36 at ¶¶ 9-11; Docket No. 36 at Exh. H; Docket No. 29-5 at Exh. C.
. See, e.g., Cedars Sinai Med. Ctr. v. Mid-West Nat’l Life Ins. Co., 118 F.Supp.2d 1002, 1008 (C.D.Cal. 2000) (finding, where there was no authorization provided by the insurer, that "verification [alone could not] be construed as a binding contractual agreement"); Principal Fin. Grp., 412 F.Supp.2d at 1042 (finding, where defendants "provided both verification of coverage and explicit authorization,” that it would be reasonable to conclude based on the written authorizations that defendants intended to be bound”); Enloe Med. Ctr., 2011 WL 6396517, at *5 (finding that “in some instances, a contract may be created on an authorization call”). Indeed, "[providers regularly rely on the authorizations ... as representations that health plans will pay for the authorized services subject only to lawful exclusions.” Docket No. 36 at ¶ 12.
. See Docket No. 34.at 3:12-15.
. See Docket No. 29 at 2:10-15; Docket No. 1, Exh. A at ¶¶ 12, 13.
. Id. at ¶ 29. In its opposition, CHOMP reiterates this expectation, stating that "it understood [Aetna's] representations regarding coverage as a promise of payment subject only to lawful exclusions." Docket No. 34 at 8:14-15.
. Docket No. 36 at Exh. H,
. Docket No. 29 at 7. See also Docket Nos. 29-4, 29-5 at Exhs. B. C.
. As the parties made clear at oral argument on May 5, 2015, the heart of this dispute is
. See Docket No. 1, Exh. A at ¶¶ 39, 40.
. Ca! Bus. & Prof.Code § 17200.
. Cel-Tech Commc’ns, Inc. v. Los Angeles Cellular Tel. Co., 20 Cal.4th 163, 180, 83 Cal.Rptr.2d 548, 973 P.2d 527 (1999) (citing Podolsky v. First Healthcare Corp., 50 Cal. App.4th 632, 647, 58 Cal.Rptr.2d 89 (1996)) (internal quotations omitted).
. Docket No. 1, Exh. A at ¶ 39.
. Specifically, the authorization contained the following language: "Except for services considered to be an emergency, if the health benefit plan includes an out-of-network benefit component for the use of a non-participating provider, claims received for eligible services may be processed at the out-of-network or non-preferred benefit level. Members may be réspohsible for higher copayments, deductibles, and coinsurance, plus any charges by the provider in excess of the amounts covered by the plan for services provided by out-of-network provider. These excess amounts may be significant.” Docket No. 36 at Exhs. C, N; see also Docket No. 1, Exh. A at ¶¶ 5-6, 15-16.
. Docket No. 36 at Exh. H.
. See id., at Exh. I.
. See Docket No. 29 at 2:10-15; Docket No. 1, Exh. A at ¶¶ 7-8, 12-13, 17-18.
. Both statutes explicitly caution that they do not “expand or alter the benefits available” under the policy between the patient and the insurer. See Cal. Health & Safety Code § 1371.8; Cal. Ins.Code § 796.04.
. CHOMP also alleges that “Aetna's failure to pay [CHOMP’s] claim for emergency services provided to Patient constitute^] an unfair business practice in violation of” Section 17200. Docket No. 1, Exh. A at ¶ 40. CHOMP specifically asserts that “Aetna [was] required to pay [CHOMP] for the emergency
.Cal. Health & Safety Code § 1371.4; Cal. Health & Safety Code § 1371 states that "[a] health care service plan ... shall reimburse claims or any portion of any claim ... as soon as practicable, but no later than 30 working days after receipt of the claim by the health care service plan.” The timing of Aet-na's payment is not at issue here — CHOMP’s complaint admits that Aetna at least partially paid CHOMP within 30 days of each visit. See Docket No. 1, Exh. A at ¶¶ 7-8, 12-13, 1718.
. Bell v. Blue Cross of California, 131 Cal. App.4th 211, 220, 31 Cal.Rptr.3d 688 (2005).
. CHOMP states in its opposition that its "unfair competition claim is based ... in part on [Aetna's] misrepresentations regarding coverage.” Docket No. 34 at 9:1-2. To the extent CHOMP asserts this claim under the "fraudulent” prong of the UCL, such an assertion also fails as a matter of law. As previously discussed, neither Aetna’s verification nor authorizations for the July visit constituted misrepresentations. That logic extends to the verifications and authorizations for the February and September visits as well.
. McBride v. Boughton, 123 Cal.App.4th 379, 394, 20 Cal.Rptr.3d 1.15 (2004).
. Smith v. Bentson, 127 Cal.App.Supp. 789, 793, 15 P.2d 910 (1932).
. Docket No. 1, Exh. A at ¶ 52.
. Id. at ¶ 11.
. Authorize, Black's Law Dictionary (10th ed. 2014).
. Docket No. 34 at 10.
. Aetna conflates a claim for open book account with a claim for account stated. "To constitute an account stated ... there must be an agreement that the balance is correct, and a promise, either express or implied, to pay such balance.” Joslin v. Gertz, 155 Cal. App.2d 62, 67, 317 P.2d 155 (1957). A claim for open book account does not require an agreement between the parties as to the balance. Id. at 65-66, 317 P.2d 155.
. See Docket No. 1, Exh. A at 7.
. Wright v. Loaiza, 177 Cal. 605, 606-07, 171 P. 311 (1918).
. Interstate Grp. Adm’rs v. Cravens, Dargan & Co., 174 Cal.App.3d 700, 708, 220 Cal.Rptr. 250 (1985) (citing Tillson v. Peters, 41 Cal. App.2d 671, 678, 107 P.2d 434 (1940)) (internal quotation marks omitted).
. Id. (citing Joslin, 155 Cal.App.2d at 65, 317 P.2d 155) (internal quotation marks omitted).
. "A book account is described as ‘open’ when the debtor has made some payment on the account, leaving a balance due.” Id.
. See Starnet Int’l AMC Inc. v. Kafash, Case No. 09-cv-04301, 2011 WL 845908, at *8 (N.D.Cal. Mar. 8, 2011) (citing Cochran v. Rubens, 42 Cal.App.4th 481, 485, 49 Cal. Rptr.2d 672 (1996); Thompson v. Machado, 78 Cal.App.2d 870, 874, 178 P.2d 838 (1947)).
. See Docket No. 36 at Exhs. C, N; Principal Fin. Grp., 412 F.Supp.2d at 1042 (finding that "it would be reasonable to conclude based on the written authorizations that defendants intended to be bound, subject to the provisions of the policy”).
. See Docket No. 36 at Exhs. D, E, J, K, O, P.
. Interstate Grp. Adm’rs, 174 Cal.App.3d at 708, 220 Cal.Rptr. 250.
. See Docket No. 42 at 7.
.' Interstate Grp. Adm'rs, 174 Cal.App.3d at 708, 220 Cal.Rptr. 250.
. Once the reasonable value of the services is determined by the jury based on the quan-turn meruit claim, the jury will then be able to decide whether the book account is open or closed and whether the amount due is accurate.
Reference
- Full Case Name
- COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA v. AETNA LIFE INSURANCE COMPANY
- Cited By
- 4 cases
- Status
- Published