This case was last updated from Los Angeles County Superior Courts on 03/05/2020 at 00:48:48 (UTC).

ELAINE COURTNEY VS HEALTH NET, INC, ET AL.

Case Summary

On 11/16/2018 ELAINE COURTNEY filed a Contract - Insurance lawsuit against HEALTH NET, INC. This case was filed in Los Angeles County Superior Courts, Stanley Mosk Courthouse located in Los Angeles, California. The Judge overseeing this case is DANIEL S. MURPHY. The case status is Pending - Other Pending.

Case Details Parties Documents Dockets

 

Case Details

  • Case Number:

    *******5327

  • Filing Date:

    11/16/2018

  • Case Status:

    Pending - Other Pending

  • Case Type:

    Contract - Insurance

  • County, State:

    Los Angeles, California

Judge Details

Presiding Judge

DANIEL S. MURPHY

 

Party Details

Plaintiff

COURTNEY ELAINE

Defendants

HEALTH NET INC

CONIFER VALUE-BASED CARE LLC

COMMUNITY FAMILY CARE MEDICAL GROUP IPA INC.

Attorney/Law Firm Details

Plaintiff Attorneys

SHERNOFF WILLIAM MARTIN

SHERNOFF WILLIAM M

Defendant Attorneys

KLEIN ELISE DALE

NAEVE WILLIAM D

PIMSTONE GREGORY N.

MADDIGAN MICHAEL MCDONALD

 

Court Documents

Answer

1/4/2019: Answer

Motion for Summary Judgment

11/15/2019: Motion for Summary Judgment

Proof of Personal Service

11/15/2019: Proof of Personal Service

Declaration - DECLARATION OF DIANE PENN IN SUPPORT OF MOTION FOR SUMMARY JUDGMENT OF DEFENDANT CONIFER VALUE-BASED CARE, LLC AGAINST PLAINTIFF

11/15/2019: Declaration - DECLARATION OF DIANE PENN IN SUPPORT OF MOTION FOR SUMMARY JUDGMENT OF DEFENDANT CONIFER VALUE-BASED CARE, LLC AGAINST PLAINTIFF

Order - ORDER PROPOSED ORDER

12/10/2019: Order - ORDER PROPOSED ORDER

Declaration - DECLARATION OF SYUZANNA GRIGORYAN IN SUPPORT OF MOTION FOR SUMMARY JUDGMENT OF DEFENDANTS HEALTH NET COMMUNITY SOLUTIONS, INC. AND HEALTH NET OF CALIFORNIA, INC.

1/21/2020: Declaration - DECLARATION OF SYUZANNA GRIGORYAN IN SUPPORT OF MOTION FOR SUMMARY JUDGMENT OF DEFENDANTS HEALTH NET COMMUNITY SOLUTIONS, INC. AND HEALTH NET OF CALIFORNIA, INC.

Proof of Personal Service

1/21/2020: Proof of Personal Service

Proof of Personal Service

1/23/2020: Proof of Personal Service

Declaration - DECLARATION OF JOHN HALL IN SUPPORT

1/23/2020: Declaration - DECLARATION OF JOHN HALL IN SUPPORT

Memorandum of Points & Authorities

1/23/2020: Memorandum of Points & Authorities

Order - ORDER RE DEFENDANT CONIFER VALUE-BASED CARE, LLC'S DEMURRER

3/18/2019: Order - ORDER RE DEFENDANT CONIFER VALUE-BASED CARE, LLC'S DEMURRER

Reply - REPLY REPLY IN SUPPORT OF DEFENDANT'S DEMURRER

3/11/2019: Reply - REPLY REPLY IN SUPPORT OF DEFENDANT'S DEMURRER

Proof of Service (not Summons and Complaint)

3/5/2019: Proof of Service (not Summons and Complaint)

Reply - Reply Defendant Conifer Value-Based Care, LLC's Reply to Plaintiff's Opposition to Defendant's Demurrer

2/14/2019: Reply - Reply Defendant Conifer Value-Based Care, LLC's Reply to Plaintiff's Opposition to Defendant's Demurrer

Demurrer - without Motion to Strike

1/14/2019: Demurrer - without Motion to Strike

Demurrer - without Motion to Strike

1/25/2019: Demurrer - without Motion to Strike

Civil Case Cover Sheet

11/16/2018: Civil Case Cover Sheet

Notice of Case Assignment - Unlimited Civil Case

11/16/2018: Notice of Case Assignment - Unlimited Civil Case

55 More Documents Available

 

Docket Entries

  • 05/19/2020
  • Hearing05/19/2020 at 08:30 AM in Department 32 at 111 North Hill Street, Los Angeles, CA 90012; Jury Trial

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  • 05/07/2020
  • Hearing05/07/2020 at 08:30 AM in Department 32 at 111 North Hill Street, Los Angeles, CA 90012; Final Status Conference

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  • 04/03/2020
  • Hearing04/03/2020 at 08:30 AM in Department 32 at 111 North Hill Street, Los Angeles, CA 90012; Hearing on Motion for Summary Judgment

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  • 04/03/2020
  • Hearing04/03/2020 at 08:30 AM in Department 32 at 111 North Hill Street, Los Angeles, CA 90012; Hearing on Motion for Summary Judgment

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  • 04/03/2020
  • Hearing04/03/2020 at 08:30 AM in Department 32 at 111 North Hill Street, Los Angeles, CA 90012; Hearing on Motion for Summary Judgment

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  • 03/03/2020
  • Docketat 08:30 AM in Department 32, Daniel S. Murphy, Presiding; Jury Trial - Not Held - Advanced and Continued - by Court

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  • 02/20/2020
  • Docketat 08:30 AM in Department 32, Daniel S. Murphy, Presiding; Final Status Conference - Not Held - Advanced and Continued - by Court

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  • 02/03/2020
  • Docketat 08:30 AM in Department 32, Daniel S. Murphy, Presiding; Hearing on Motion for Summary Judgment - Not Held - Advanced and Continued - by Court

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  • 02/03/2020
  • Docketat 08:30 AM in Department 32, Daniel S. Murphy, Presiding; Hearing on Motion for Summary Judgment - Not Held - Rescheduled by Party

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  • 01/31/2020
  • Docketat 08:30 AM in Department 32, Daniel S. Murphy, Presiding; Hearing on Motion for Summary Judgment - Not Held - Advanced and Continued - by Court

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65 More Docket Entries
  • 01/14/2019
  • DocketDemurrer - without Motion to Strike; Filed by Conifer Value-Based Care, LLC (Defendant)

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  • 01/04/2019
  • DocketAnswer; Filed by Health Net, Inc (Defendant)

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  • 11/28/2018
  • DocketProof of Service of Summons; Filed by Elaine Courtney (Plaintiff)

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  • 11/28/2018
  • DocketProof of Service of Summons; Filed by Elaine Courtney (Plaintiff)

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  • 11/28/2018
  • DocketNotice of Case Management Conference; Filed by Clerk

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  • 11/28/2018
  • DocketProof of Service of Summons; Filed by Elaine Courtney (Plaintiff)

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  • 11/16/2018
  • DocketSummons (on Complaint); Filed by Clerk

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  • 11/16/2018
  • DocketCivil Case Cover Sheet; Filed by Elaine Courtney (Plaintiff)

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  • 11/16/2018
  • DocketComplaint; Filed by Elaine Courtney (Plaintiff)

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  • 11/16/2018
  • DocketNotice of Case Assignment - Unlimited Civil Case; Filed by Clerk

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Tentative Rulings

Case Number: 18STCV05327    Hearing Date: March 22, 2021    Dept: 32

elaine courtney,

Plaintiff,

v.

HEALTH NET, INC.; et. al.

Defendants.

Case No.: 18STCV05327

Hearing Date: March 22, 2021

[TENTATIVE] order RE:

(1) DEFENDANT cOMMUNITY FAMILY cARE MEDICAL GROUP IPA, INC.’S Motion for determination of good faith settlement

(2) DEFENDANT cONIFER VALUE-BASED CARE, LLC’S Motion for determination of good faith settlement

BACKGROUND

This is an insurance coverage dispute case.

On November 16, 2018, plaintiff Elaine Courtney (Plaintiff), a Medi-Cal HMO member, filed this action against her health care service plan (defendant Health Net, Inc. ("Health Net")), her independent physician’s association (moving party defendant Community Family Care Medical Group IPA, Inc. (“CFC”), and CFC’s former third-party administrator or management service organization (defendant Conifer Value-Based Care, LLC ("Conifer")) alleging that they failed to properly arrange or provide for the medical care that she needed. She alleges that over a period of ten months, CFC and Conifer delayed arranging medical care that she needed, and she was in severe pain during this time. She also alleges that Health Net wrongfully transferred her from an out-of-network hospital to an in-network hospital and did not appropriately respond to the complaints she submitted to Health Net.

Essentially, Plaintiff alleges that she had to wait a long time until she was approved for treatment she desired for a rectocele (pelvic floor injury) and this wait was caused in part by Defendants.

ANALYSIS

The Tech-Bilt decision sets out factors to apply when determining good faith of a settlement when a tortfeasor challenges the good faith of that settlement. These factors include (1) a rough approximation of the plaintiff’s total recovery and the settlors’ proportionate liability, (2) the amount paid in settlement, (3) a recognition that a settlor should pay less in settlement than if found liable after a trial, (4) the allocation of the settlement proceeds among plaintiffs, (5) the settlor’s financial condition and insurance policy limits, if any, and (6) evidence of any collusion, fraud, or tortious conduct between the settlor and plaintiffs aimed at making the nonsettling parties pay more than their fair share. (Tech-Bilt, Inc. v. Woodward-Clyde & Associates (1985) 38 Cal.3d 488, 499.)

“[A] defendant’s settlement figure must not be grossly disproportionate to what a reasonable person, at the time of the settlement, would estimate the settling defendant's liability to be. . . . The party asserting the lack of good faith, who has the burden of proof on that issue (§ 877.6, subd. (d)), should be permitted to demonstrate, if he can, that the settlement is so far ‘out of the ballpark’ in relation to these factors as to be inconsistent with the equitable objectives of the statute.” (Id. at 499–500.)

Defendants CFC and Conifer move for an order deeming the proposed settlement between Plaintiff and Defendants CFC and Conifer to be in good faith. The terms of the settlement are as follows: Plaintiff agrees to an entry of dismissal of the operative Original Complaint, filed on or about November 16, 2018, with prejudice as to defendant CFC and Conifer in exchange for the payment to plaintiff of $400,000 by Conifer and $185,000 by CFC.

Defendant CFC, though disputing liability, contends that the settlement takes into consideration the evidence or lack of evidence against CFC, including plaintiff’s damages. (Klein’s Decl. ¶12.) CFC argues that the proportion of liability and settlement amount are fair and reasonable given that Plaintiff’s claims of pain lasted less than a year. Thus, CFC argues that the settlement of $185,000 is within the range of potential liability for CFC. Further, CFC argues there is no existence of collusion, fraud or tortious conduct aimed to injure the interest of non-settling defendants.

Defendant Conifer, though disputing liability, contends that the settlement takes into consideration the evidence or lack of evidence against Conifer, including plaintiff’s damages. (Naeve’s Decl. ¶13.) Conifer argues that the proportion of liability and settlement amount are fair and reasonable given that Plaintiff’s claims of pain lasted less than a year. Thus, Conifer argues that the settlement of $400,000 is within the range of potential liability for CFC. Further, Cogen argues there is no existence of collusion, fraud or tortious conduct aimed to injure the interest of non-settling defendants.

In opposition, Defendant Health Net does not challenge CFC or Conifer’s evaluation of the case. Health Net argues that this Court should consider if there was collusion, fraud, or

tortious conduct aimed to injure the interests of the non-settling defendants. The evidence shows that there was not collusion, fraud or tortious conduct and that this was an arms’ length agreement. This settlement took place over a lengthy period of time with the assistance of two mediations. While Health Net is disappointed that there was not a global settlement, many cases to do reach a global settlement, and the good faith settlement statutes recognize.

Health Net correctly states that claims for “contractual indemnity” may survive a determination of good faith. (See, e Bay Development, Ltd. v. Superior Court, (1990) 50

Cal.3d 1012, 1019.) However, Code of Civil Procedure, Section 877.6(c) provides: “A determination by the court that the settlement was made in good faith shall bar any other joint tortfeasor or co-obligor from any further claims against the settling tortfeasor or co-obligor for equitable comparative contribution, or partial or comparative indemnity, based on comparative negligence or comparative fault.”

The Court finds the settlement between Plaintiff and Defendants CFC and Conifer is a good faith settlement pursuant to Code of Civil Procedure, Section 877.6 and in accordance with Tech-Bilt, Inc. factors.

Accordingly, the motion is GRANTED.

Case Number: 18STCV05327    Hearing Date: February 10, 2021    Dept: 32

ELAINE COURTNEY,

Plaintiff,

v.

HEALTH NET, INC., et al.

Defendants.

Case No.: 18STCV05327

Hearing Date: February 10, 2021

[TENTATIVE] order RE:

DEFENDANTs health net of california, inc. and health net community solutions, inc.’S MOTION FOR SUMMARY JUDGMENT OR, IN THE ALTERNATIVE, SUMMARY ADJUDICATION

BACKGROUND

This is an insurance coverage dispute case.

Plaintiff Elaine Courtney (“Plaintiff”) asserts two causes of action against the Defendants Health Net of California, Inc. incorrectly sued herein as Health Net, Inc. (“HNCI”) and Health Net Community Solutions, Inc. (“HNCS”) (collectively “Defendants”), which are the moving parties:[1] (1) breach of the implied covenant of good faith and fair dealing; and (2) violation of Civil Code section 3428.

Essentially, Plaintiff alleges that she had to wait a long time until she was approved for treatment she desired for a rectocele (pelvic floor injury) and this wait was caused in part by Defendants.

A. Factual and procedural history

On November 16, 2018, Plaintiff filed her complaint against HNCI, Community Family Care Medical Group IPA, Inc. (“CFC”), Conifer Value-Based Care, LLC (“Conifer”), and Does 1 to 10.

On December 10, 2019, the Court so-ordered a stipulation between Plaintiff and Defendants whereby Plaintiff’s complaint was amended that any reference to HNCI shall be read to refer to both HNCI and HNCS.

Plaintiff alleges as follows. Plaintiff was insured under a Medi-Cal plan issued by Defendants under plan number 97801893F. (Complaint ¶ 7.) Defendants delegated to CFC the primary function of authorizing treatment and approving referrals to specialists and CFC delegated this responsibility to Conifer. (Id. ¶ 8.) In December 2016, Plaintiff was diagnosed with having a rectocele. (Id. ¶ 10.) Plaintiff visited CFC/Conifer designated doctors, who made requests for her to have a surgery consult and imaging done to show the rectocele through a defecatory study, but CFC/Conifer denied the request and did not approve it until many months later while Plaintiff was suffering from pain. (Id. ¶¶ 12-22.) Plaintiff continued to suffer pain and was hospitalized, but Defendants advised that she needed to be transferred to a different hospital against medical recommendation. (Id. ¶¶ 23-24.) Defendants misled her that she would be transferred back to her original hospital to provide proper treatment. (Id. ¶ 25.)

Plaintiff submitted an expedited grievance to Defendants, but they did not authorize Plaintiff for her needed surgery, instead sending her back to CFC and Conifer. (Id. ¶ 27.) Plaintiff received authorization to visit USC Keck Hospital where she received some treatment. (Id. ¶ 28.) Plaintiff submitted an expedited grievance to Defendants, but they treated her request as a standard request (i.e., non-expedited). (Id. ¶ 31.) Plaintiff saw some more doctors, one of which agreed that she had rectocele and surgery was required, but she did not get authorization. (Id. ¶¶ 32-34.)

Plaintiff submitted another expedited grievance to Defendants. (Id. ¶ 35.) Finally, on September 26, 2017, Defendants retroactively approved Plaintiff for surgery. (Id. ¶ 36.) Plaintiff eventually had her necessary surgery. (Id. ¶¶ 37-38.)

Based on these events, Plaintiff generally alleges that Defendants breached their duty of good faith and fair dealing by failing to ensure that she had access to medically necessary treatment, delaying and denying necessary treatment, and failing to adequately respond to her grievances. (Id. ¶ 40.)

On January 13, 2021, Plaintiff settled her claims against CFC and Conifer.

B. The instant motion before the Court

On January 23, 2021, Defendants filed the instant motion for summary judgment or in the alternative summary adjudication.

On February 1, 2021, Plaintiff opposed.

On February 5, 2021, Defendants filed a reply.

On February 8, 2021, Defendants filed a response to Plaintiff’s separate statement of material facts.

The Court has reviewed all timely filed papers. The Court notes that the Reply Declaration of Alyssa Saviss (Defendants’ counsel) purports to include Exhibits AA-MM, but this declaration includes only exhibits up to Exhibit Z. The Court cannot consider exhibits not actually filed.

LEGAL STANDARD

Code of Civil Procedure section 437c, subdivision (c) states: “The motion for summary judgment shall be granted if all the papers submitted show that there is no triable issue as to any material fact and that the moving party is entitled to a judgment as a matter of law.” A material fact is one that “must relate to some claim or defense in issue under the pleadings, and it must also be essential to the judgment in some way.” (Riverside County Community Facilities District v. Bainbridge 17 (1999) 77 Cal.App.4th 644, 653.) The court may not weigh the evidence. (Mann v. Cracchiolo (1985) 38 Cal.3d 18, 39.) A motion for summary adjudication may be made by itself or as an alternative to a motion for summary judgment and shall proceed in all procedural respects as a motion for summary judgment. (Code Civ. Proc., § 437c, subd. (f)(2).) The moving party bears an initial burden of production to make a prima facie showing of the nonexistence of any triable issue of material fact, and if he does so, the burden shifts to the opposing party to make a prima facie showing of the existence of a triable issue of material fact. (Aguilar v. Atlantic Richfield Co. (2001) 25 Cal.4th 826, 850-51.)

REQUEST FOR JUDICIAL NOTICE

Defendants request the Court to take judicial notice of:

(1) Exhibit 1, which is the Medi-Cal Managed Healthcare Directory; and

(2) the fact that the Medi-Cal Managed Care Health Plan Directory (i.e., Exhibit 1) lists Defendant “Health Net Community Solutions,” not Defendant Health Net of California, Inc., as the health plan that provides Medi-Cal coverage in Los Angeles County.

“Judicial notice may not be taken of any matter unless authorized or required by law.” (Evid. Code, § 450.) Evidence Code section 452 lists matters that are subject to judicial notice.

In regard to the documents for which the Court grants judicial notice, the Court is not mandated to accept the truth of its their contents or the parties’ interpretation of those contents. (Joslin v. H.A.S. Ins. Brokerage (1986) 184 Cal.App.3d 369, 374.)

The Court denies both requests. Defendants fail to attach the material for Exhibit 1 as claimed. (Cal. Rules of Court rules 3.1113(l), 3.1306(c) [“A party requesting judicial notice of material under Evidence Code sections 452 or 453 must provide the court and each party with a copy of the material.”].) The Court addresses this denial further below.

DISCUSSION

Defendants move for summary judgment on the complaint seemingly on three grounds as paraphrased by the Court:

(1) all claims against HNCI must be dismissed because the other named defendant HCNS is the one that issued Plaintiff her Medi-Cal coverage and handled her claims;

(2) CFC is responsible for providing treatment and authorizing and approving specialist referrals because it is Plaintiff’s primary care provider, i.e., Plaintiff is not liable for acts or omissions of its contracted medical service provider CFC;

(3) HCNS provided services to Plaintiff in a timely way that does not breach its contractual obligations, i.e., it did not deny, delay, or modify medical services.

Although not specifically specified as such (see notice of motion 2:17-3:2), Defendants move for summary adjudication on issues based on the same reasons as set forth above.

In opposition, Plaintiff argues that Defendants (1) fail to meet their burden to show that they acted according to the terms of their health plan and (2) acted in bad faith by failing to arrange for timely access to medical care and by failing to properly resolve Plaintiff’s grievances. 

In reply, Defendants argue that: (1) Plaintiff’s complaints about the acts and omissions of CFC and Confer provide no basis for Plaintiff’s claims against Defendants; (2) Plaintiff’s novel interpretation of California Code of Regulations title 18, section 1300.67.2.2 et seq. is inconsistent with California law and cannot provide a basis for her bad faith claim; and (3) Plaintiff fails to create a triable issue of material fact regarding Defendants’ handling of grievances and Plaintiff’s claim for violation of Civil Code section 3428.

A. Procedural issues

As a preliminary matter, the Court first must address certain procedural issues involving California Rules of Court, rule 3.1350, all of which the Court independently identifies. Because of these procedural issues, the Court exercises its discretionary authority to only consider Defendants’ motion as one for summary judgment, not one for summary adjudication in the alternative. (See Truong v. Glasser (2009) 181 Cal.App.4th 102, 118 [“[T]he court’s power to deny summary judgment on the basis of failure to comply with California Rules of Court, rule 3.1350 is discretionary, not mandatory.”].)

1. Notice of motion

Defendants’ motion is one for summary judgment and summary adjudication in the alternative, but Defendants do not comply with procedural requirements to allow the Court to consider it as a motion made in the alternative for summary adjudication.

California Rules of Court, rule 3.1350(b) requires a notice of motion for summary adjudication to identify each specific cause of action and claims for damages for which summary adjudication is sought.

Here, Defendants’ notice of motion does not identify that it seeks summary adjudication of any specific issues. Presumably, the motion seeks summary adjudication of issues corresponding to the causes of action, but Plaintiff does not have proper notice of that. (See Homestead Savings v. Superior Court (1986) 179 Cal.App.3d 494, 498 [“Any gain in efficiency the court might make by adjudicating sub-issues not targeted by the motion is outweighed by the unfairness to the defending party who has not been properly notified of the danger of such a ruling.”].)

2. Defendants’ separate statement

Code of Civil Procedure section 437c, subdivisions (b)(1) and (f)(2) require a motion for summary judgment and adjudication to include a separate statement of material facts. “The failure to comply with this requirement of a separate statement may in the court’s discretion constitute a sufficient ground for denying the motion.” (Code Civ. Proc., § 437c, subd. (b)(1).)

California Rules of Court, rule 3.1350(d) requires a motion for summary judgment and adjudication to have a separate statement that separately identifies each cause of action that is the subject of the motion and each supporting material fact claimed to be without dispute. “If summary adjudication is sought, whether separately or as an alternative to the motion for summary judgment, the specific cause of action, affirmative defense, claims for damages, or issues of duty must be stated specifically in the notice of motion and be repeated, verbatim, in the separate statement of undisputed material facts.” (Cal. Rules of Court., rule 3.1350(b).) This separate statement for summary adjudication also must follow a specific format of identifying the issues in a heading before discussing the material facts. (Id., rule 3.1350(g).)

Here, Defendants’ separate statement includes 29 total facts and no delineated issues. This violates the rules set forth above.

B. All claims against HCNI

Before addressing the focus of the parties’ arguments, the Court first addresses Defendants’ argument that all claims against HCNI should be dismissed because only HCNS is the properly named defendant since HCNS is the one that issued Plaintiff her Medi-Cal coverage and handled her claims.

Defendants’ argument is limited to a few paragraphs with no citations. (Motion points and authorities 5:16-22, 10:18-27.) The separate statement sets forth facts, as disputed, which purport to show that HCNS, not HCNI, is a licensed health plan that provides Medi-Cal health plans in Los Angeles Count. (See Undisputed Material Facts (“UMF”) ¶¶ 1-3.) However, the key evidence supporting this claim is Defendants’ Request for Judicial Notice, which the Court denied because the subject material was not provided.

The Court anticipates that Defendants likely will argue at the hearing that it should have accessed the link[2] provided in Defendants’ Request for Judicial Notice that purportedly shows a list of the Medi-Cal Managed Care Health Plan Directory that does not include HCNI. However, even if the Court were to access that link, there is no indication of the effective dates, i.e., whether it covers the relevant time period of Plaintiff’s claims. Additionally, judicial notice of the existence of a list could be proper, but the truth of the contents cannot.

Defendants do not meet their burden to show that HCNI is an improper defendant.

Accordingly, the Court denies summary judgment sought by HCNI against all claims on this basis.

C. Whether Defendants can rely on the Evidence of Coverage to meet their burden

Much of Defendants’ remaining arguments rely on Plaintiff’s Evidence of Coverage (“EOC”) to show that they acted according to the terms of the health plan.

Defendants do not provide the specific contractual coverage document between HCNS and Plaintiff. Instead, they provide only the “Member Handbook.” (Hall Decl. Ex. A.)[3] That document is only a “summary” of policies and rules:

Your Member Handbook is also called the Combined Evidence of Coverage and Disclosure Form. It gives only a summary of Health Net policies and rules. You must look at the contract between Health Net and the California Department of Health Care Services (DHCS) to learn the exact terms and conditions of coverage. Call Member Services if you would like a copy of the contract.

(Id. HN 0000704.) By the document’s terms, it is not a contract between Defendants and Plaintiff. The entire contract providing the exact terms and conditions of coverage is needed. Plaintiff’s argument is persuasive.

In reply, Defendants request the Court to reject this argument because: (1) other courts have regularly relied on an individual member’s EOC to set forth the terms of coverage and (2) the EOC is consistent with the coverage terms required by the State of California. (See reply 7:26-28.) Regarding the first argument, Defendants cite two cases: (1) Watanabe v. California Physicians’ Service (2008) 169 Cal.App.4th 56, 67 (Watanabe); and (2) Orthopedic Specialists of Southern California v. Public Employees’ Retirement System (2014) 228 Cal.App.4th 644, 648 (Orthopedic Specialists). Defendants’ reliance is misplaced. In Watanabe, the plaintiff sought the court to rely on the EOC, which Plaintiff here does not. Additionally, Watanabe refers to documents referenced by and incorporated into the EOC. The relevant language of the EOC, as set forth above, refers to itself only as a summary and identifies an external contract that is not explicitly incorporated into the EOC. In Orthopedic Specialists, the plaintiff sought the court to rely on the EOC, which Plaintiff here does not, and the EOC was attached to the operative pleading to show the contractual terms that was properly considered for the purposes of a demurrer. Defendants do not otherwise cite any additional supporting authority. Regarding the second argument, Defendants cite to the Exhibits KK to MM annexed to the Saviss Declaration, which the Court already noted Defendants did not file, and Exhibit A to the Hall Declaration without any explanation why it defeats Plaintiff’s argument.

But Defendants do not meet their burden to show this is the case for the purposes of this summary judgment motion.

Defendants fail to show what the contractual terms are. It is theoretically possible that the EOC captures the contractual terms of coverage here. Without knowing the exact contractual terms, the Court cannot evaluate whether Defendants’ conduct breached the contractual obligations. Defendants cannot simply rely on other evidence that HNCS delegated the duties to CFC (Hall Decl. Ex. B) because it is not specifically set out for the purposes of this motion that it covers the contract provided to Plaintiff because no contract is actually provided. HNCS is also still involved in some way with the grievance/appeal process (id. Ex. A HN0000750-HN0000751).

Therefore, Defendants cannot meet their burden to show that they satisfied these contractual terms that have not been established in the first place. Because Defendants cannot meet their initial burden on this issue, the Court largely denies Defendants’ motion as stated further below.

D. Whether Defendants can be held liable for the failures and omissions of medical providers and delegated medical groups

Defendants argue that they cannot be held liable for the failures and omissions of medical providers and delegated medical groups because they have immunity under the Knox-Keene Act.

A managed care organization may be sued for failure to furnish covered benefits to its members or enrollees or for harm resulting from delay in furnishing such benefits, on various theories. However, a health care service plan is not vicariously liable for the negligence of a person or entity (e.g., an independent practice association or medical group) with whom it contracts to provide medical care for members or to perform utilization review to decide whether a member’s request for medical care will be provided. (Health & Safety Code, § 1371.25 [“A plan, any entity contracting with a plan, and providers are each responsible for their own acts or omissions, and are not liable for the acts or omissions of, or the costs of defending, others.”].)

In support of their argument that they are immune under Health & Safety Code section 1371.25, Defendants correctly note that “[t]he implied covenant of good faith and fair dealing does not impose substantive terms and conditions beyond those to which the parties actually agreed.” (Avidity Partners, LLC v. State of California (2013) 221 Cal.App.4th 1180, 1204.) And here, assuming the Court credits Defendants’ argument that the EOC is the contract, there is no breach on conduct that violates non-existent terms of the contract. But Defendants cannot rely on the EOC as the contract. Defendants cannot rely on the EOC to show that they delegated duties by HCNS to a primary care provider in the contracted benefits provided to Plaintiff. (PacifiCare of California v. Bright Medical Associates, Inc. (2011) 198 Cal.App.4th 1451, 1463 [finding that Section 1371.25 does not bar joint and several liability if both the plan and provider contribute to the insured patient’s damages].)

The EOC is not the contract. Had Defendants provided sufficient proof to show the contract benefits and that Defendants delegated those benefits entirely away without reservation, the Court would have been inclined to agree with Defendants that Watanabe, supra, 169 Cal.App.4th at p. 64 and Martin v. PacifiCare of California (2011) 198 Cal.App.4th 1390, 1401-1402 control on Plaintiff’s first cause of action. Plaintiff could not otherwise rely on California Code of Regulations title 18, section 1300.67.2.2 et seq. to show that Defendants still have non-waivable duties primarily because the subject regulations do not create a cause of action for this misconduct.

The Court denies summary judgment on this basis.

E. Whether Defendants alternatively complied with their contractual obligations

Defendants alternatively argue that Plaintiff’s bad faith claim fails because HNCS acted in accordance with the terms of the EOC. But as already discussed above, the EOC is not the contract. Whether Defendants satisfied the grievance procedures in the EOC is not dispositive because the contract itself is missing.

The Court denies summary judgment on this basis.

F. Plaintiff’s second cause of action for violation of Civil Code section 3428

Defendants argue that HCNS provided services to Plaintiff in a timely way that did not violate Civil Code section 3428.

In 1999, the Legislature enacted Civil Code section 3248, which provides a cause of action for members of a health plan when they were negligently denied, delayed, or modified necessary treatment:

[A] health care service plan or managed care entity . . . shall have a duty of ordinary care to arrange for the provision of medically necessary health care service to its subscribers and enrollees, where the health care service is a benefit provided under the plan, and shall be liable for any and all harm legally caused by its failure to exercise that ordinary care when both of the following apply:

(1) The failure to exercise ordinary care resulted in the denial, delay, or modification of the health care service recommended for, or furnished to, a subscriber or enrollee.

(2) The subscriber or enrollee suffered substantial harm.

(Civ. Code, § 3428, subd. (a).)

Here, again there is insufficient evidence to show what the contracted covered benefits are. Therefore, the Court cannot evaluate whether Plaintiff’s sought care “is a benefit provided under the plan.” But assuming that it is, there are triable issues of fact whether HCNS exercised ordinary care given the number and extent of Plaintiff’s grievances. A jury could reasonably find that HCNS should have acted more quickly.

The Court denies summary adjudication on this basis.

CONCLUSION

Defendants’ motion for summary judgment and summary adjudication in the alternative is DENIED.

Defendants are to give notice of this ruling.


[1] The other named defendants have settled Plaintiff’s claims brought against them.

[2] https://www.dhcs.ca.gov/individuals/Pages/MMCDHealthPlanDir.aspx

[3] The Court overlooks the admissibility issue involving this document for the purposes of this motion because Plaintiff fails to object on this basis. (Se Hall Decl. ¶ 3 [failing to identify Exhibit A as a “true and correct copy” of the purported material].)

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