Justia Health Law Opinion Summaries

Four consolidated appeals presented a question of whether medical providers who provided services under California’s Medi-Cal program were entitled to reimbursement for the costs of providing in-house medical services for their own employees through “nonqualifying” self-insurance programs. Even for nonqualifying self-insurance programs, however, the Provider Reimbursement Manual allowed providers to claim reimbursement for reasonable costs on a “claim-paid” basis. Oak Valley Hospital District (Oak Valley) and Ridgecrest Regional Hospital (Ridgecrest) had self-insurance programs providing health benefits to their employees. Claims for in-house medical services to their employees were included in cost reports submitted to the State Department of Health Care Services (DHS). DHS allowed the costs when Oak Valley and Ridgecrest employees received medical services from outside providers but denied costs when the medical services were provided in-house. DHS determined claims paid to Oak Valley and Ridgecrest out of their self-insurance plan for in-house medical services rendered to their employees were not allowable costs. The trial court granted Oak Valley and Ridgecrest's the writ petitions on grounds that costs of in-house medical services were reimbursable so long as they were “ ‘reasonable’ ” as defined by the Provider Reimbursement Manual. DHS appealed in each case. After review, the Court of Appeal concluded Oak Valley’s and Ridgecrest’s self-insurance programs did not meet the requirements of a qualified plan under CMS guidelines and Provider Reimbursement Manual. The Court of Appeal rejected DHS’s contention that Oak Valley and Ridgecrest costs relating to in-house medical services for their employees were inherently unreasonable. To the extent DHS argued the cost reports were not per se unreasonable, but unreasonable under the circumstances of the actual treatments of Oak Valley and Ridgecrest employees, the Court determined the evidence in the record supports the trial court’s findings that expert testimony established Oak Valley and Ridgecrest incurred actual expenses in providing in-house medical services for their employees that were not otherwise reimbursed. Accordingly, the Court affirmed the trial court’s granting of the petitions for writs of administrative mandate. View "Oak Valley Hospital Dist. v. Cal. Dept. of Health Care Services" on Justia Law

Plaintiffs Rafi Ghazarian and Edna Betgovargez had a son, A.G., with autism. A.G. received applied behavior analysis (ABA) therapy for his autism under a health insurance policy (the policy) plaintiffs had with defendant California Physicians’ Service dba Blue Shield of California (Blue Shield). Mental health benefits under this policy are administered by defendants Magellan Health, Inc. and Human Affairs International of California (collectively Magellan). By law, the policy had to provide A.G. with all medically necessary ABA therapy. Before A.G. turned seven years old, defendants Blue Shield and Magellan approved him for 157 hours of medically necessary ABA therapy per month. But shortly after he turned seven, defendants denied plaintiffs’ request for 157 hours of therapy on grounds only 81 hours per month were medically necessary. Plaintiffs requested the Department of Managed Health Care conduct an independent review of the denial. Two of the three independent physician reviewers disagreed with the denial, while the other agreed. As a result, the Department ordered Blue Shield to reverse the denial and authorize the requested care. Plaintiffs then filed this lawsuit against defendants, asserting breach of the implied covenant of good faith and fair dealing against Blue Shield, and claims for intentional interference with contract and violations of Business and Professions Code section 17200 (the UCL) against defendants. Defendants each successfully moved for summary judgment. As to the bad faith claim, the trial court found that since one of the independent physicians agreed with the denial, Blue Shield acted reasonably as a matter of law. As to the intentional interference with contract claim, the court found no contract existed between plaintiffs and A.G.’s treatment provider with which defendants could interfere. Finally, the court found the UCL claim was based on the same allegations as the other claims and thus also failed. After its review, the Court of Appeal concluded summary judgment was improperly granted as to the bad faith and UCL claims. "[I]t is well established that an insurer may be liable for bad faith if it unfairly evaluates a claim. Here, there are factual disputes as to the fairness of defendants’ evaluation. . . .There are questions of fact as to the reasonability of these standards. If defendants used unfair criteria to evaluate plaintiffs’ claim, they did not fairly evaluate it and may be liable for bad faith." Conversely, the Court found summary judgment proper as to the intentional interference with contract claim because plaintiffs failed to show any contract with which defendants interfered. View "Ghazarian v. Magellan Health" on Justia Law

Defendants Silverado Senior Living Management, Inc., and Subtenant 350 W. Bay Street, LLC dba Silverado Senior Living – Newport Mesa appealed a trial court's denial of its petition to compel arbitration of the complaint filed by plaintiffs Diane Holley, both individually and as successor in interest to Elizabeth S. Holley, and James Holley. Plaintiffs filed suit against defendants, who operated a senior living facility, for elder abuse and neglect, negligence, and wrongful death, based on defendants’ alleged substandard treatment of Elizabeth. More than eight months after the complaint was filed, defendants moved to arbitrate based on an arbitration agreement Diane had signed upon Elizabeth’s admission. At the time, Diane and James were temporary conservators of Elizabeth’s person. The court denied the motion, finding that at the time Diane signed the document, there was insufficient evidence to demonstrate she had the authority to bind Elizabeth to the arbitration agreement. Defendants argued the court erred in this ruling as a matter of law, and that pursuant to the Probate Code, the agreement to arbitrate was a “health care decision” to which a conservator had the authority to bind a conservatee. Defendants relied on a case from the Third District Court of Appeal, Hutcheson v. Eskaton FountainWood Lodge, 17 Cal.App.5th 937 (2017). After review, the Court of Appeal concluded that Hutcheson and other cases on which defendants relied are distinguishable on the facts and relevant legal principles. "When the Holleys signed the arbitration agreement, they were temporary conservators of Elizabeth’s person, and therefore, they lacked the power to bind Elizabeth to an agreement giving up substantial rights without her consent or a prior adjudication of her lack of capacity. Further, as merely temporary conservators, the Holleys were constrained, as a general matter, from making long-term decisions without prior court approval." Accordingly, the trial court was correct that the arbitration agreement was unenforceable as to Elizabeth. Furthermore, because there was no substantial evidence that the Holleys intended to sign the arbitration agreement on their own behalf, it could not be enforced against their individual claims. The Courttherefore affirmed the trial court’s order denial to compel arbitration. View "Holley v. Silverado Senior Living Management" on Justia Law

A juvenile court has the authority to order vaccinations for dependent children under its jurisdiction. Recently enacted Health and Safety Code section 120372, subdivision (d)(3)(C) provides that a state public health officer (SPHO) or a doctor designated by a SPHO "may revoke the medical exemption." The Court of Appeal held that section 120372, subdivision (d)(3)(C) does not deprive the juvenile court of that authority.After determining that this case was not moot, the court rejected father's contention that the juvenile court had no legal authority to revoke the vaccination exemptions from a past treating physician and to order that the children be vaccinated. The court held that evidence in the record supported the juvenile court's finding that the children needed vaccinations. The court also held that there is no statutory bar to preclude the juvenile court from ordering dependent children to receive medically necessary vaccinations. Finally, the court held that the juvenile court could reasonably find that the past treating physician did not know the children's current need for vaccinations and father's remaining contentions do not show grounds for reversal. View "In re S.P." on Justia Law

Objector, a conservatee subject to conservatorship under the Lanterman-Petris-Short Act, contested the petition to reappoint a public guardian as his conservator. On appeal, objector contends the trial court violated Welfare and Institutions Code section 5350, subdivision (d)(2), and denied him due process by failing to commence the jury trial within 10 days of his demand for trial.The Court of Appeal was deeply troubled by the significant delay of over four months in holding a trial on objector's petition, especially given the lack of any justification by the court for most of the delay. The court emphasized the statutory obligation of trial courts to hold a jury trial within 10 days, with only a limited exception for a 15-day continuance if requested by the proposed conservatee. However, the court held that the trial court's failure to commence trial within 10 days of the jury trial demand did not support dismissal of the petition. Rather, the time limit in section 5350, subdivision (d)(2), is directory, not mandatory, because the Legislature has not expressly provided for dismissal of the conservatorship petition if a trial is not held within 10 days. Furthermore, objector was not prejudiced and denied due process. Accordingly, the court affirmed the judgment. View "Conservatorship of Jose B." on Justia Law

Goros, age 92, filed suit alleging that Kindred Healthcare violated the Elder Abuse and Dependent Adult Civil Protection Act (Welf. & Inst. Code 15600) by failing to timely obtain medical treatment for her after she suffered a stroke while a patient at their nursing home. After Goros’s death about two years later, her daughter substituted in as successor in interest and added a claim for wrongful death. The trial court granted the defendants summary judgment, predicated on the exclusion of the opinion of the plaintiff’s expert on the issue of causation.The court of appeal affirmed. The plaintiff’s expert failed to provide any basis for his opinions and stated only that “his opinion is based on his experience and documented medical literature.” The plaintiff cites no evidence contradicting the court’s finding that her expert did not have the education or experience to render an opinion about the cause or treatment of Goros’s stroke, as required by Evidence Code section 720(a). Qualifications on a related subject matter are insufficient. View "Lowery v. Kindren Healthcare Operating, Inc." on Justia Law

In June 2018, plaintiffs-respondents Suzanne Yang and Doc Yang Medical Corporation sued defendants-appellants Tenet Healthcare Inc. doing business as John F. Kennedy Memorial Hospital (the hospital), its medical staff, and individual doctors, alleging defamation and nine other causes of action. Defendants filed a special motion to strike (anti-SLAPP motion) targeting only the defamation cause of action. Dr. Yang alleged that since March 2016, defendants conspired to drive her practice out of business in various ways, including by making defamatory statements. Defendants’ anti-SLAPP motion contended that the statements were protected activity because they were made in connection with the hospital’s peer review process, and because they were made in furtherance of the exercise of the right of free speech in connection with a public issue or an issue of public interest. Defendants also contended that Dr. Yang could not demonstrate a probability of prevailing because she consented to the peer review process that the statements were purportedly in connection with, and because the statements were privileged. Applying the California Supreme Court's recent opinion in FilmOn.com Inc. v. DoubleVerify, Inc., 7 Cal.5th 133 (2019), and concluded defendants’ conduct arose from protected activity because their allegedly defamatory statements were made in connection with an issue of public interest. Furthermore, the Court concluded Dr. Yang did not demonstrate a probability of prevailing on the merits. The Court therefore reversed the trial court, which denied the anti-SLAPP motion. View "Yang v. Tenet Healthcare Inc." on Justia Law

In January 2017, plaintiffs Lori Dougherty and Julie Lee's 89-year-old father passed away while living in Somerford Place, an elder residential care facility owned and operated by defendants Roseville Heritage Partners, Somerford Place, LLC, Five Star Quality Care, Inc., and Five Star Quality Care-Somerford, LLC. In July 2017, plaintiffs sued defendants, alleging elder abuse and wrongful death based upon the reckless and negligent care their father received while residing in defendants’ facility. Defendants appealed the trial court’s denial of their motion to compel arbitration and stay the action, contending the arbitration agreement did not contain any unconscionable or unlawful provisions. Alternatively, defendants argued the court abused its discretion by invalidating the agreement as a whole, rather than severing the offending provisions. The Court of Appeal found the arbitration agreement at issue here was "buried within the packet at pages 43 through 45," and "[b]ased on the adhesiveness of the agreement, and the oppression and surprise present," the Court concluded the trial court properly found the Agreement was imposed on a “take it or leave it” basis and evinced a high degree of procedural unconscionability. Under the sliding scale approach, only a low level of substantive unconscionability was required to render the arbitration agreement unenforceable. Likewise, the Court concurred that the arbitration agreement was substantively unconscionable, "particularly given the accompanying evidence of procedural unconscionability." The Court found no abuse of discretion in the trial court's declination to sever the offending provisions of the agreement, rather than invalidate the entire agreement. View "Dougherty v. Roseville Heritage Partners" on Justia Law

The Court of Appeal reversed the district court's grant of summary judgment in favor of Aetna. In plaintiff's first cause of action, plaintiff alleged that Aetna violated Health & Safety Code section 1371.4. In plaintiff's second cause of action, plaintiff alleged that Aetna breached an implied contract based on its prior dealing with Aetna by not paying for the emergency medical services it rendered to a patient covered by Aetna's health care service plan. The court held that there were triable issues of fact as to whether plaintiff provided and billed for emergency services and was entitled to reimbursement from Aetna. Accordingly, the court remanded for further proceedings. View "San Jose Neurospine v. Aetna Health of California, Inc." on Justia Law

The Court of Appeal affirmed the trial court's grant of summary judgment for defendant, a managed care health plan that provides health coverage to low-income individuals under Medi-Cal.The court held that the legislative history of Welfare and Institutions Code section 14105.28, along with the statement of legislative intent within the statute itself, indicate that the Legislature intended the APR-DRG (All Patient Refined Diagnosis Related Group) rates to apply to out-of-network inpatient poststabilization services under Medi-Cal. Consistent with the legislature's intent, the court interpreted the phrase "managed care inpatient days" to refer to services provided pursuant to a managed care contract, that is, in-network services. View "Dignity Health v. Local Initiative Health Care Authority of Los Angeles County" on Justia Law