Aton Center, Inc. v. Premera Blue Cross

CourtDistrict Court, S.D. California
DecidedFebruary 16, 2021
Docket3:20-cv-00501
StatusUnknown

This text of Aton Center, Inc. v. Premera Blue Cross (Aton Center, Inc. v. Premera Blue Cross) is published on Counsel Stack Legal Research, covering District Court, S.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Aton Center, Inc. v. Premera Blue Cross, (S.D. Cal. 2021).

Opinion

1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 SOUTHERN DISTRICT OF CALIFORNIA 10 11 ATON CENTER, INC., a Case No.: 3:20-cv-00501-WQH-BGS California corporation, 12 ORDER Plaintiff, 13 v. 14 PREMERA BLUE CROSS, a 15 corporation; and DOES 1 through 10, inclusive, 16 Defendants. 17 18 HAYES, Judge: 19 The matter pending before the Court is the Motion to Dismiss filed by Defendant 20 Premera Blue Cross. (ECF No. 17). 21 I. PROCEDURAL BACKGROUND 22 On December 27, 2019, Plaintiff Aton Center, Inc. commenced this action by filing 23 a Complaint in the Superior Court of California for the County of San Diego, assigned case 24 number 37-2019-00068777-CU-BC-NC, against Defendant Premera Blue Cross and 25 DOES 1 through 10, inclusive. (ECF No. 1-4). On March 16, 2020, Defendant removed 26 the action to this Court pursuant to 28 U.S.C. § 1332, diversity jurisdiction, 28 U.S.C. § 27 1441(b), and 28 U.S.C. § 1446. (ECF No. 1). 28 1 On April 17, 2020, Defendant filed a Motion to Dismiss of Plaintiff’s Complaint for 2 failure to state a claim upon which relief can be granted pursuant to Federal Rule of Civil 3 Procedure 12(b)(6). (ECF No. 7). On April 22, 2020, the parties filed a Joint Motion to 4 Consolidate Cases. (ECF No. 8). On August 17, 2020, the Court granted the Motion to 5 Dismiss and denied the Joint Motion to Consolidate Cases. (ECF No. 12). 6 On September 16, 2020, Plaintiff filed a Motion for Leave to File a First Amended 7 Complaint. (ECF No. 13). On October 19, 2020, the Court granted the Motion for Leave 8 to File a First Amended Complaint. (ECF No. 15). 9 On October 21, 2020, Plaintiff filed an Amended Complaint. (ECF No. 16). 10 Plaintiff alleges that “Defendant[] breached [its] agreements with Plaintiff and/or 11 committed other wrongful acts and omissions by refusing to pay Plaintiff the represented 12 and agreed upon/represented amount, but rather paid different and significantly lower (and 13 inconsistent) previously undisclosed amounts for treatment, leaving an unpaid balance of 14 $319,291.43 owing from Defendant[] to Plaintiff which has caused Plaintiff substantial 15 hardship.” Id. at 8. Plaintiff brings the following nine causes of action: (1) breach of oral 16 contract; (2) breach of implied contract; (3) promissory estoppel; (4) quantum meruit; (5) 17 intentional misrepresentation (fraudulent inducement); (6) negligent misrepresentation; (7) 18 intentional concealment; (8) violation of Business & Professions Code § 17200; and (9) 19 open book account. See id. at 9-18. Plaintiff seeks “general, special, restitutionary and/or 20 compensatory damages”; prejudgment interest; expenses, attorney’s fees, and other costs; 21 “an injunction and/or other equitable relief enjoining the conduct alleged herein, an 22 accounting, the appointment of a receiver over Defendant[] and/or other appropriate 23 equitable relief”; and “such other and further relief as the Court may deem just and proper.” 24 Id. at 18. 25 On November 3, 2020, Defendant filed a Motion to Dismiss of Plaintiff’s Amended 26 Complaint for failure to state a claim upon which relief can be granted pursuant to Federal 27 28 1 Rule of Civil Procedure 12(b)(6). (ECF No. 17). On November 23, 2020, Plaintiff filed 2 a Response in opposition. (ECF No. 18). On December 7, 2020, Defendant filed a Reply. 3 (ECF No. 21). 4 II. ALLEGATIONS OF THE AMENDED COMPLAINT 5 “Plaintiff . . . is a corporation authorized to do and doing business in the City of 6 Encinitas, County of San Diego, State of California . . . as an inpatient residential substance 7 abuse treatment facility . . . .” (ECF No. 16 at 2). Plaintiff “provided residential treatment 8 care services which were or should have been covered by health insurance policies which 9 . . . were provided, sponsored, supplied, underwritten, administered and/or implemented 10 by Defendant[] . . . .” Id. “Defendant . . . is a corporation authorized to do and doing 11 substantial insurance and/or health plan/policy administration business in the city of 12 Encinitas, county of San Diego, and state of California, within the jurisdiction of this 13 court.” Id. “This case involves nine different individuals who received residential 14 treatment care at [Plaintiff’s facility] which was covered under healthcare plans written, 15 issued and/or administered by Defendant . . . .” Id. 16 While the subject plans/policies were in effect, AH, AP, BG, CP, JH, KF, MC, TM and WD, who were insured under plans issued by Defendant[] 17 sought treatment with Plaintiff. Plaintiff took reasonable steps to verify 18 available benefits, including contacting Defendant[], as directed by Defendant[], including calling Defendant[] at phone numbers provided by 19 Defendant[], to verify insurance benefits. [Plaintiff] was an out of network 20 provider to [Defendant] as to the claims at issue herein. As an out of network provider, the verification of benefit (VOB) process was very important to 21 [Plaintiff] which needed accurate information concerning coverage and 22 payment rates so that [Plaintiff] and its patient[s] could make informed financial decisions as to admission to [Plaintiff’s] residential treatment care 23 program. At all times relevant herein, Defendant[] knew that the information 24 it was providing during the VOB process was material and would be relied on by [Plaintiff] and its patients. As is discussed in more detail in paragraphs 8- 25 26 27 1 Defendant requests the Court to take judicial notice of Exhibit 1 (ECF No. 17-3) and Exhibit 2 (ECF No. 17-4) in support of Defendant’s Motion to Dismiss (ECF No. 17). See ECF No. 17-2. The Court has not 28 1 16 below, . . . [Plaintiff] was advised in these verification of benefit (VOB) calls that the policies provided for and Defendant[] would pay for inpatient 2 treatment, based on the usual, customary and reasonable rate (UCR) and/or 3 prior payment history.

4 In addition to verifying benefits, [Plaintiff] was required to and did 5 obtain authorization for all of the specific treatment provided to the patients with claims at issue herein. Multiple authorizations were obtained for each 6 patient. As [Plaintiff] provides residential treatment care, and not partial 7 hospitalization or any outpatient services, the authorizations were for the residential treatment care services provided [to] AH, AP, BG, CP, JH, KF, 8 MC, TM and WD which were billed under the applicable Revenue Code 1002. 9 Id. at 3-4. 10 Defendant’s representatives informed Plaintiff’s employees over the phone that 11 “claims would be paid based on the UCR which meant that for AH[][, CP, JH, KF, and 12 WD] Defendant[] would pay 50% of [Plaintiff]’s billed charges” and “for AP[, BG, MC, 13 and TM] Defendant[] would pay 70% of [Plaintiff]’s billed charges.” Id. at 4-8. “After 14 admission, and on multiple occasions, [Plaintiff] obtained authorization from Defendant[] 15 to provide residential treatment care to” each of the nine patients. Id. at 5-8. 16 Within the past two years, at Encinitas, California, the Defendant[] 17 breached [its] agreements with Plaintiff and/or committed other wrongful acts 18 and omissions by refusing to pay Plaintiff the represented and agreed upon/represented amount, but rather paid different and significantly lower 19 (and inconsistent) previously undisclosed amounts for treatment, leaving an 20 unpaid balance of $319,291.43 owing from Defendant[] to Plaintiff which has caused Plaintiff substantial hardship.

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Aton Center, Inc. v. Premera Blue Cross, Counsel Stack Legal Research, https://law.counselstack.com/opinion/aton-center-inc-v-premera-blue-cross-casd-2021.