Aetna Health Plans of California, Inc. v. Yucaipa-Calimesa Joint Unified School District

85 Cal. Rptr. 2d 672, 72 Cal. App. 4th 1175, 99 Daily Journal DAR 5861, 99 Cal. Daily Op. Serv. 4591, 1999 Cal. App. LEXIS 572
CourtCalifornia Court of Appeal
DecidedJune 10, 1999
DocketE021913
StatusPublished
Cited by6 cases

This text of 85 Cal. Rptr. 2d 672 (Aetna Health Plans of California, Inc. v. Yucaipa-Calimesa Joint Unified School District) is published on Counsel Stack Legal Research, covering California Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Aetna Health Plans of California, Inc. v. Yucaipa-Calimesa Joint Unified School District, 85 Cal. Rptr. 2d 672, 72 Cal. App. 4th 1175, 99 Daily Journal DAR 5861, 99 Cal. Daily Op. Serv. 4591, 1999 Cal. App. LEXIS 572 (Cal. Ct. App. 1999).

Opinion

Opinion

WARD, J.

Cross-complainant and appellant Aetna Health Plans of California, Inc. (Aetna), appeals after the trial court granted summary judgment in favor of cross-defendant and respondent Yucaipa-Calimesa Joint Unified School District (Yucaipa), and dismissed Aetna’s cross-complaint against Yucaipa.

The case presents the question whether indemnity or contribution may be had between two insurers that each potentially provided coverage for the same incident, and in particular whether one insurer may allege a cause of action for contribution or indemnity from the other insurer when both insurers’ conduct may have contributed to a single tort injury.

The trial court granted summary judgment on the theory that, as a matter of law, no cause of action could be maintained for contribution or indemnity as between the two insurers, because their liability for damages is several under Proposition 51. 1 Because the liability of each insurer has been made several, and therefore divisible, by statute, and the plaintiff’s recovery against each insurer for noneconomic damages is limited only to the amount *1179 proportional to the insurer’s fault, we conclude that Aetna’s cross-complaint could not properly state any cause of action for contribution or equitable indemnity. Accordingly, we affirm.

Facts and Procedural History

Aetna was the primary insurer, and Yucaipa was the secondary insurer, of medical benefits for plaintiff’s decedent, David Goodrich. David was employed by the County of San Bernardino. Through Aetna, one of the insurance carriers that provided health care plans for county employees, David selected a health maintenance organization (HMO) as his medical provider. Aetna’s HMO plan provided that any member, such as David, would be treated in a physician group, with one member of the group as his primary care physician. Any other care would have to be arranged by special referral. 2

David’s spouse, Teresa, the plaintiff in the underlying action below, was employed by Yucaipa. Yucaipa provided self-insured medical coverage to Teresa. As Teresa’s spouse, David was also eligible to be covered by Yucaipa’s medical coverage.

*1180 Ojn June 9, 1992, David collapsed and was taken to a hospital. After he was stabilized, David obtained a referral on June 23, 1992, from his primary care physician for exploratory surgery with another plan specialist. The specialist performed diagnostic surgery on July 6, 1992. David was diagnosed, with a rare form of stomach cancer, leimosarcoma. On July 28, 1992, the specialist told David and Teresa that the plan doctors did not have the expertise to treat this rare form of cancer, and David should be referred to the City of Hope, an out-of-plan provider. Aetna approved the referral to City of Hope on August 5, 1992.

The City of Hope doctor evaluated David and recommended high-dose chemotherapy and a bone marrow transplant. David was scheduled to begin treatment on October 2, 1992. When David went to the City of Hope on October 2, however, tests revealed that the cancer had metastasized to his liver. On October 6, therefore, the City of Hope doctor recommended modifying the treatment plan to begin with standard-dose chemotherapy to see if the tumors on David’s liver would respond. David was scheduled to begin the treatment at City of Hope on October 10, 1992.

As a result of the change in David’s condition, his primary care physician asked for referral authorizations for a consultation on chemotherapy at City of Hope, and for the plan’s oncologist to determine whether the standard-dose chemotherapy should be done by in-plan doctors. On October 23, 1992, Aetna denied authorization for CT scans, lab work and initial chemotherapy at City of Hope, because the in-plan oncologist could provide this treatment. On November 18, 1992, Aetna also denied approval of the bone marrow transplant, on the ground that the treatment was experimental in its application to already metastasized leimosarcoma.

David’s disease stabilized under standard-dose chemotherapy over the next several months. In February of 1993, David and Teresa heard about a cryosurgical procedure that might benefit him, which was available at St. John’s Hospital (St. John’s), an out-of-plan provider. After spending time researching the procedure, David asked for a referral. David’s primary care physician referred David to an in-plan oncologist for a consultation on August 5, 1993. Three weeks later, the oncologist recommended that David go to St. John’s for consultation. That same day, August 26, 1993, David’s primary care physician asked Aetna for approval of the referral to St. John’s. Because he wanted treatment without delay, David scheduled an appointment for September 3, 1993, at St. John’s, without having obtained prior approval from Aetna. David had cryosurgery on September 22, 1993. Aetna initially denied coverage for the cryosurgery, in November of 1993, on the *1181 ground that David had not gotten prior authorization for use of an out-of-plan facility. Ultimately, Aetna did pay most of the bills for this cryosurgery, though it denied payment for follow-up treatment, e.g., follow-up CT scans.

After the cryosurgery in September of 1993, David returned to work. In October of 1994, he began to experience further difficulties, and in December of 1994, he had to stop working. By January of 1995, David’s abdomen became distended, his legs became swollen, and he was unable to eat. David went to St. John’s to discuss the possibility of another cryosurgery. On January 11, 1995, David asked his plan primary care physician for a referral for the cryosurgery.

On January 17, 1995, David went to St. John’s. He had not received prior approval for the admission from Aetna. Yucaipa had, however, preapproved the procedure. 3

David underwent surgery, but the cryosurgery could not be completed because David’s tumor was too large. On January 18, 1995, Aetna sent a letter denying coverage because: (1) David had gone to St. John’s on self-referral; (2) there was no prior authorization for the hospital admission; and (3) St. John’s was a nonparticipating facility.

David remained hospitalized at St. John’s in the critical care unit from the date of surgery, January 17, 1995, until his death on March 15, 1995. Teresa was left with approximately $500,000 in outstanding, unpaid medical bills, largely from St. John’s for the January 17, 1995, surgery and follow-up care. Neither Aetna, which had denied approval for the procedures and care, nor Yucaipa, which had granted approval, paid the outstanding bills, until about May of 1996, when Yucaipa paid bills totaling approximately $500,000.

Teresa filed an action against Aetna and the HMO medical group in March of 1996. The operative complaint is the fourth amended complaint. She alleged causes of action against Aetna, in her capacity as David’s successor in interest, for breach of the covenant of good faith and fair dealing, and for breach of contract.

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85 Cal. Rptr. 2d 672, 72 Cal. App. 4th 1175, 99 Daily Journal DAR 5861, 99 Cal. Daily Op. Serv. 4591, 1999 Cal. App. LEXIS 572, Counsel Stack Legal Research, https://law.counselstack.com/opinion/aetna-health-plans-of-california-inc-v-yucaipa-calimesa-joint-unified-calctapp-1999.