California Spine and Neurosurgery Institute v. United Healthcare Insurance Company

• Court: District Court, N.D. California
• Decided: February 24, 2020
• Docket: 5:19-cv-02417
• Status: Unknown

Opinion

8 UNITED STATES DISTRICT COURT

9 NORTHERN DISTRICT OF CALIFORNIA 10 SAN JOSE DIVISION 11

12 CALIFORNIA SPINE AND Case No. 19-CV-02417-LHK NEUROSURGERY INSTITUTE, 13 Plaintiff, ORDER GRANTING MOTION TO DISMISS QUANTUM MERUIT CLAIM 14 v. WITH PREJUDICE 15 Re: Dkt. No. 32 UNITED HEALTHCARE INSURANCE 16 COMPANY, et al., 17 Defendants. 18 Plaintiff California Spine and Neurosurgery Institute (“Plaintiff”) sues Defendant United 19 Healthcare Insurance Company (“Defendant”) and Does 1 through 25 for breach of implied 20 contract, breach of express contract, and quantum meruit. ECF No. 30 ¶¶ 8-67 (“SAC”). Before 21 the Court is Defendant’s motion to dismiss Plaintiff’s quantum meruit claim. ECF No. 32. 22 Having considered the parties’ submissions, the relevant law, and the record in this case, the Court 23 GRANTS Defendant’s motion to dismiss Plaintiff’s quantum meruit claim with prejudice. 24 I. BACKGROUND 25 A. Factual Background 26 Plaintiff is a “medical facility dedicated to the care and treatment of spine injuries and/or 27 1 conditions” located in Campbell, California. SAC ¶¶ 1, 8. In March 2018 and July 2018, Plaintiff 2 rendered “medically necessary” “spine surgeries” to three patients—D.B., L.M., and M.B.— 3 whose health insurance benefits were sponsored and administered by Defendant.1 Id. ¶¶ 12, 20, 4 25, 30, 36, 41. All three patients worked for the same employer and were “beneficiar[ies] of a 5 health plan . . . administered” by Defendant. Id. ¶¶ 11, 24, 35. All patients owned an 6 identification card from Defendant that was presented to medical providers in order to obtain 7 medical care. Id. Defendant instructed patients to present an identification card “to assure 8 medical providers that they would be paid for medical care . . . at a percentage of the usual and 9 customary value for such care.” Id. Furthermore, patients’ employer published a summary of the 10 benefits of patients’ medical plans and noted that the plans paid 70% of eligible expenses for care 11 from out-of-network providers.2 Id. ¶¶ 12, 25, 36. Plaintiff was an out-of-network provider under 12 the health plans administered by Defendant. Id. ¶ 9. 13 D.B., L.M., and M.B. experienced back pain and sought medical services from Plaintiff. 14 Id. ¶¶ 13, 26, 37. For each patient, Plaintiff contacted Defendant to verify medical eligibility 15 benefits, and Defendant’s client services representatives “either expressly or impliedly assured” 16 Plaintiff that Defendant “carried the financial responsibility to pay for” all three patients’ 17 “anticipated medical care at 70% of the usual and customary value for such care.” Id. ¶¶ 17, 27, 18 38. For D.B., Plaintiff received an authorization letter in response to Plaintiff’s request for 19 coverage of services that determined that the treatment was medically necessary. Id. ¶ 14-16. For 20 patients L.M. and M.B., Defendant’s client services representatives allegedly told Plaintiff that 21 “no pre-authorization was required” after Plaintiff “telephoned [Defendant] to verify . . . medical 22 eligibility benefits.” Id. ¶¶ 27, 29, 38, 40. 23 24 1 Plaintiff “limited the disclosure of patient identification information pursuant to the privacy 25 provisions of the federal Health Insurance Portability & Accountability Act (“HIPAA”) §§ 1320(d) et seq., and the California Constitution, art. 1, § 1.” SAC at 4 n.1. 26 2 The SAC alleges that D.B. and L.M. both have the same health plan but that M.B. has a different one. SAC ¶¶ 12, 25, 36. According to the SAC, the health plans reimburse 70% of expenses for 27 care from out-of-network providers with slight differences based on deductibles. Id. For the purposes of Defendant’s motion to dismiss, these differences are immaterial. 1 Based on the existence of an identification card issued by Defendant, the pre-authorization 2 discussions and the authorization letter, and “the express and/or implied resultant assurances” that 3 Plaintiff “would be paid at least 70% of the usual and customary value of its medical services 4 anticipated to be rendered,” Plaintiff provided treatment to D.B., L.M., and M.B. and submitted 5 claims for payment at the usual and customary rate for such services. Id. ¶¶ 20-21, 30-31, 41-42. 6 Plaintiff alleges, however, that Defendant significantly underpaid Plaintiff and owes $206,909.66 7 plus interest and other costs. Id. ¶¶ 21-23, 31-34, 42-45, 69. 8 B. Procedural History 9 On December 20, 2018, Plaintiff filed suit against UHC of California doing business as 10 UnitedHealthcare of California, Apple Inc., and Does 1 through 25 in the Superior Court of Santa 11 Clara County. ECF No. 1-1 Ex. A. Plaintiff’s complaint asserted three causes of action against 12 defendants: breach of implied in fact contract, breach of express contract, and quantum meruit. Id. 13 On February 25, 2019, Plaintiff amended the complaint and replaced UHC of California with 14 United Healthcare Insurance Company. FAC ¶ 5. On April 23, 2019, Plaintiff filed a request for 15 dismissal of Apple Inc. in state court. ECF No. 1-1 Ex. E. On April 30, 2019, Plaintiff also filed a 16 request for dismissal of UHC of California in state court. ECF No. 1-1 Ex. F. United Healthcare 17 Insurance Company was the only remaining named defendant. 18 On May 3, 2019, Defendant removed the case to this Court. ECF No. 1. On May 10, 19 2019, Defendant moved to dismiss all three causes of action in Plaintiff’s First Amended 20 Complaint (“FAC”). See ECF No. 7. 21 On September 17, 2019, the Court granted in part and denied in part Defendant’s motion 22 to dismiss. ECF No. 28. First, the Court denied Defendant’s motion to dismiss Plaintiff’s claims 23 for breach of implied contract and breach of express contract because Plaintiff pled that 24 “Defendant gave ‘express and/or implied resultant assurances’ that Plaintiff ‘would be paid at least 25 70% of the usual and customary value of its medical services anticipated to be rendered.’” Id. at 6 26 (quoting FAC ¶¶ 17, 27, 38). As a result, the Court concluded that Plaintiff had adequately 27 alleged that Defendant exhibited an intent to contract. Id. at 6-7. 1 Second, the Court granted Defendant’s motion to dismiss Plaintiff’s quantum meruit claim 2 with leave to amend. Id. at 8-10. Among other things, a quantum meruit claim requires that 3 services were performed at defendant’s request. Id. at 8-9. Because Plaintiff had only alleged that 4 Plaintiff requested services, the Court dismissed the quantum meruit claim with leave to amend. 5 Id. at 9-10. The Court allowed Plaintiff to file an amended complaint but noted that “failure to 6 cure the deficiencies identified” in the Court’s Order would “result in a dismissal with prejudice of 7 the deficient claim.” ECF No. 29 at 1. 8 On October 17, 2019, Plaintiff filed its Second Amended Complaint (“SAC”) and 9 realleged the same three causes of action for breach of implied contract, breach of express 10 contract, and quantum meruit. ECF No. 30 (“SAC”). Plaintiff, however, added only two new 11 paragraphs to the SAC. See id. ¶¶ 63-64. Those paragraphs allege that “[p]rior to surgery for 12 Patient D.B., California Spine received a pre-procedure authorization letter from OrthoNet, on 13 behalf of United” and that “[p]rior to surgery for Patient L.M. and Patient M.B., California Spine 14 was informed, by agents of United as stated above, that the pre-authorization process was not 15 required.” Id. 16 On October 31, 2019, Defendant filed a motion to dismiss Plaintiff’s quantum meruit 17 claim. ECF No. 32 (“Mot.”). On November 14, 2019, Plaintiff filed an opposition brief. ECF 18 No. 35 (“Opp.”). Defendant filed a reply on November 21, 2019. ECF No. 36 (“Reply”). 19 II. LEGAL STANDARD 20 A. Motion to Dismiss Under Rule 12(b)(6) 21 Rule 8(a)(2) of the Federal Rules of Civil Procedure requires a complaint to include “a 22 short and plain statement of the claim showing that the pleader is entitled to relief.” A complaint 23 that fails to meet this standard may be dismissed pursuant to Federal Rule of Civil Procedure 24 12(b)(6). The United States Supreme Court has held that Rule 8(a) requires a plaintiff to plead 25 “enough facts to state a claim to relief that is plausible on its face.” Bell Atl. Corp. v. Twombly, 26 550 U.S. 544, 570 (2007). “A claim has facial plausibility when the plaintiff pleads factual 27 content that allows the court to draw the reasonable inference that the defendant is liable for the 1 misconduct alleged.” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009). “The plausibility standard is 2 not akin to a probability requirement, but it asks for more than a sheer possibility that a defendant 3 has acted unlawfully.” Id. (internal quotation marks omitted). Put another way, “a complaint need 4 not contain ‘detailed factual allegations,’ [but] a plaintiff must plead at least enough facts to put 5 the defendant on notice of the claim against it.” Wheeler v. MicroBilt Corp., 700 Fed. App’x 725, 6 727 (9th Cir. 2017) (quoting Iqbal, 556 U.S. at 678). For purposes of ruling on a Rule 12(b)(6) 7 motion, the Court must “accept factual allegations in the complaint as true and construe[s] the 8 pleadings in the light most favorable to the nonmoving party.” Manzarek v. St. Paul Fire & 9 Marine Ins. Co., 519 F.3d 1025, 1031 (9th Cir. 2008). 10 The Court, however, need not “assume the truth of legal conclusions merely because they 11 are cast in the form of factual allegations.” Fayer v. Vaughn, 649 F.3d 1061, 1064 (9th Cir. 2011) 12 (per curiam) (internal quotation marks omitted). Mere “conclusory allegations of law and 13 unwarranted inferences are insufficient to defeat a motion to dismiss.” Adams v. Johnson, 355 14 F.3d 1179, 1183 (9th Cir. 2004). 15 B. Leave to Amend 16 Under Rule 15(a) of the Federal Rules of Civil Procedure, leave to amend “should be 17 freely granted when justice so requires,” bearing in mind that “the underlying purpose of Rule 15 18 . . . [is] to facilitate decision on the merits, rather than on the pleadings or technicalities.” Lopez v. 19 Smith, 203 F.3d 1122, 1127 (9th Cir. 2000) (en banc). Accordingly, leave to amend generally 20 shall be denied only if allowing amendment would unduly prejudice the opposing party, cause 21 undue delay, or be futile, or if the moving party has acted in bad faith. Leadsinger, Inc. v. BMG 22 Music Publ’g, 512 F.3d 522, 532 (9th Cir. 2008). At the same time, a court is justified in denying 23 leave to amend when a plaintiff “repeated[ly] fail[s] to cure deficiencies by amendments 24 previously allowed.” See Carvalho v. Equifax Info. Servs., LLC, 629 F.3d 876, 892 (9th Cir. 25 2010). Indeed, a “district court’s discretion to deny leave to amend is particularly broad where 26 plaintiff has previously amended the complaint.” Cafasso, U.S. ex rel. v. Gen. Dynamics C4 Sys., 27 Inc., 637 F.3d 1047, 1058 (9th Cir. 2011) (quotation marks omitted). III. DISCUSSION 1 Defendant challenges Plaintiff’s claim for quantum meruit on the basis that Plaintiff has 2 not adequately alleged such a claim. “Quantum meruit (or quasi-contract) is an equitable remedy 3 implied by the law under which a plaintiff who has rendered services benefitting the defendant 4 may recover the reasonable value of those services when necessary to prevent unjust enrichment 5 of the defendant.” DPR Constr. v. Shire Regenerative Med., Inc., 204 F. Supp. 3d 1118, 1131 6 (S.D. Cal. 2016) (quoting In re De Laurentiis Entm’t. Grp. Inc., 963 F.2d 1269, 1272 (9th Cir. 7 1992) (citation omitted)). “The elements of quantum meruit are: (1) that the plaintiff performed 8 certain services for the defendant, (2) their reasonable value, (3) that they were rendered at 9 defendant’s request, and (4) that they are unpaid.” Cedars Sinai Med. Ctr. V. Mid-W. Nat. Life 10 Ins. Co., 118 F. Supp. 2d 1002, 1013 (C.D. Cal. 2000) (citing Haggerty v. Warner, 115 Cal App. 11 2d 468, 475 (1953)). 12 As before, the Court focuses on the third element necessary to plead a quantum meruit 13 claim. At the outset, the Court notes that Plaintiff does not argue that Defendant requested 14 services for L.M. and M.B. See Opp. at 4-6. When a plaintiff fails to argue in support of a cause 15 of action in opposition to a defendant’s motion, that claim is abandoned. See Campbell v. Feld 16 Entm’t, Inc., 75 F. Supp. 3d 1193, 1204 (N.D. Cal. 2014) (finding claims abandoned when 17 Plaintiffs did not raise them in opposition to a motion for summary judgment); Jenkins v. Cty. of 18 Riverside, 398 F.3d 1093, 1095 (9th Cir. 2005) (same). Nonetheless, even if Plaintiff did not 19 abandon the quantum meruit claim as it relates to services for L.M. and M.B., the SAC alleges that 20 Defendant’s purported “requests for services” were only made after “staff at California Spine 21 telephoned United to verify . . . medical eligibility benefits.” SAC ¶¶ 27, 29, 38, 40. 22 For D.B., Plaintiff argues that, unlike before, Plaintiff has sufficiently pled facts 23 establishing the third element for a quantum meruit claim because Defendant made an express 24 request for Plaintiff to render services to D.B. “in the form of a pre-procedure authorization letter.” 25 Opp. at 5 (citing SAC ¶ 63). However, Plaintiff explicitly alleges that the pre-procedure 26 authorization letter for D.B. was issued “in response to California Spine’s request for coverage of 27 1 services.” SAC ¶ 14. 2 Such allegations are fatal to Plaintiff’s quantum meruit claim, as Plaintiff explicitly pleads 3 that any authorization provided by Defendant was only made in response to Plaintiff’s request. As 4 the Court held in its prior order, numerous decisions have recognized that a “cause of action for 5 quantum meruit [fails] when . . . the defendant has not made a specific request for those services.” 6 Gateway Rehab and Wellness Ctr., Inc. v. Aetna Health of Cal., Inc., 2013 WL 1518240, at *4 7 (C.D. Cal. Apr. 10, 2013) (citation omitted); Cal. Spine & Neurosurgery Inst. v. United 8 Healthcare Servs., Inc., 2018 WL 6074567, at *2 (C.D. Cal. June 28, 2018) (dismissing quantum 9 meruit claim without prejudice because Plaintiff “d[id] not bolster its allegations that Defendant 10 expressly requested services”); Cmty. Hosp. of the Monterey Peninsula v. Aetna Life Ins. Co., 119 11 F. Supp. 3d 1042, 1051-52 (N.D. Cal. 2015) (“Authorizing, by definition, means ‘to give legal 12 authority’ or ‘to formally approve.’ In the health insurance context, it is the patient who firsts 13 requests service in the form of treatment. Then, the provider . . . must seek authorization to 14 provide such treatment from the insurer . . . . No reasonable jury could conclude that [provider] 15 ‘performed services at [insurer’s] request,’ when in fact [provider] initiated contact with [insurer] 16 as to authorization.” (alterations adopted)); Barlow Respiratory Hosp. v. Cigna Health & Life Ins. 17 Co., 2016 WL 7626446, at *3 (C.D. Cal. Sep. 30, 2016) (“It is undisputed that Defendant did not 18 request that Plaintiff provide [the patient] with medical services. Rather, [the patient] requested 19 medical services from Plaintiff, who then contacted Defendant to verify [the patient’s] coverage 20 eligibility. The undisputed facts thus show that Plaintiff cannot establish the third element of its 21 quantum meruit claim.” (citations omitted)); Day v. Alta Bates Med. Ctr., 98 Cal. App. 4th 243, 22 249 (2002) (“[W]hen the services are rendered by the plaintiff to a third person, the courts have 23 required that there by a specific request therefor from the defendant . . . .”). 24 Again, this case is on all fours with Summit Estate, Inc. v. Cigna Healthcare of California, 25 Inc., 2017 WL 4517111 (N.D. Cal. Oct. 10, 2017), where the Court held that “[e]ven assuming 26 that Defendants verified coverage and authorized Plaintiff to provide . . . services through these 27 alleged representations, Plaintiffs have not alleged enough facts to plausibly suggest that 1 Defendants requested Plaintiff to render those services because, as alleged in Plaintiff’s complaint, 2 Plaintiff initiated contact with Defendants to verify coverage and seek authorization.” 2017 WL 3 4517111, at *11. That same conclusion follows here. 4 Accordingly, the Court GRANTS Defendant’s motion to dismiss Plaintiff’s quantum 5 meruit claim. In its prior order, the Court explained that “failure to cure the deficiencies 6 identified” in the Court’s Order would “result in a dismissal with prejudice of the deficient claim.” 7 ECF No. 29 at 1. Additionally, Plaintiff already had the opportunity to amend the complaint, and 8 the Court's “discretion to deny leave to amend is particularly broad where plaintiff has previously 9 amended the complaint.” Cafasso, 637 F.3d at 1058. Because Plaintiff has failed to cure 10 deficiencies previously identified in the Court’s prior order, the Court finds that amendment would 11 be futile and dismisses Plaintiff’s quantum meruit claim with prejudice. 12 IV. CONCLUSION 13 For the foregoing reasons, the Court GRANTS Defendant’s motion to dismiss Plaintiff’s 14 quantum meruit claim with prejudice. 15 IT IS SO ORDERED. 16 17 Dated: February 24, 2020 18 ______________________________________ LUCY H. KOH 19 United States District Judge 20 21 22 23 24 25 26 27