Desert Healthcare District v. Pacificare, FHP, Inc.

94 Cal. App. 4th 781, 114 Cal. Rptr. 2d 623, 2001 Daily Journal DAR 13143, 2001 Cal. Daily Op. Serv. 10586, 2001 Cal. App. LEXIS 2930
CourtCalifornia Court of Appeal
DecidedNovember 30, 2001
DocketNo. E026961
StatusPublished
Cited by41 cases

This text of 94 Cal. App. 4th 781 (Desert Healthcare District v. Pacificare, FHP, Inc.) 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
Desert Healthcare District v. Pacificare, FHP, Inc., 94 Cal. App. 4th 781, 114 Cal. Rptr. 2d 623, 2001 Daily Journal DAR 13143, 2001 Cal. Daily Op. Serv. 10586, 2001 Cal. App. LEXIS 2930 (Cal. Ct. App. 2001).

Opinion

Opinion

RAMIREZ, P. J.

Desert Healthcare District (Desert Healthcare) appeals from an order dismissing its second amended complaint following an order sustaining the demurrer of PacifiCare, FHP, Inc. (PacifiCare). Desert Healthcare alleges that PacifiCare (1) violated Health and Safety Code section 1371 of the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act) (Health & Saf. Code, § 1340 et seq.);1 (2) acted negligently; and (3) violated the unfair competition law (UCL) (Bus. & Prof. Code, § 17200 et seq.). We find no merit to Desert Healthcare’s claims and affirm.

Statement of Facts

Desert Healthcare is the owner of a hospital in Palm Springs. PacifiCare is a health care service plan licensed to do business under the Knox-Keene Act. PacifiCare contracted with Desert Physicians Association (DPA) to provide medical services to PacifiCare’s subscribers. Although the complaint failed to fully describe the PacifiCare/DPA contract, the demurrer and response adequately clarified that it was a capitation agreement, i.e., PacifiCare paid DPA a flat fee per person to provide physicians and obtain hospital services for PacifiCare’s subscribers. DPA subsequently contracted with Desert Healthcare to obtain hospital services for PacifiCare’s subscribers. At a time when Desert Healthcare was owed millions of dollars for services provided to PacifiCare’s subscribers under the contract with DPA, DPA filed for bankruptcy and thereby extinguished its debts. As a result, Desert Healthcare filed this action against PacifiCare to recover payment for the services it provided to PacifiCare’s subscribers under the contract with DPA.

In its second amended complaint, Desert Healthcare detailed several causes of action. First, Desert Healthcare asserted that PacifiCare violated section 1371 of the Knox-Keene Act, which allegedly obligated PacifiCare to pay all claims despite the contract with DPA. Next, Desert Healthcare alleged various forms of negligence, including (1) negligent failure to ensure the financial stability of DPA; (2) per se negligence for violating section 1371; and (3) negligence arising from the special relationship between Desert Healthcare and PacifiCare. Lastly, Desert Healthcare raised an unfair competition claim under the UCL based on PacifiCare’s practice of requiring [786]*786waivers from its providers and refusing to pay claims for which it had received premiums.2

The trial court sustained PacifiCare’s demurrer to the second amended complaint without leave to amend. The trial court rejected the causes of action based on section 1371, holding that health care service plans are not required to be financially responsible for the obligations of intermediaries, such as DPA. The trial court similarly rejected the negligence causes of action, holding that PacifiCare had no duty to ensure the financial stability of its intermediaries. Additionally, the trial court rejected the UCL claim, holding that (1) the Department of Corporations is exclusively responsible for regulating health care service plans; (2) the Legislature and the Department of Corporations expressly permit capitation contracts; and (3) Desert Healthcare otherwise failed to allege any unlawful, unfair, or fraudulent conduct that would have violated the UCL.

Discussion

1. Demurrer Standards

“The rules by which the sufficiency of a complaint is tested against a general demurrer are well settled. We not only treat the demurrer as admitting all material facts properly pleaded, but also ‘give the complaint a reasonable interpretation, reading it as a whole and its parts in their context. [Citation.]’ [Citation.] [1[] If the complaint states a cause of action under any theory, regardless of the title under which the factual basis for relief is stated, that aspect of the complaint is good against a demurrer. ‘[W]e are not limited to plaintiffs’ theory of recovery in testing the sufficiency of their complaint against a demurrer, but instead must determine if the factual allegations of the complaint are adequate to state a cause of action under any legal theory. . . .’ [Citations.]” (Quelimane Co. v. Stewart Title Guaranty Co. (1998) 19 Cal.4th 26, 38-39 [77 Cal.Rptr.2d 709, 960 P.2d 513] (Quelimane), italics omitted.)

2. Section 1371 of the Knox-Keene Act

Desert Healthcare primarily argues that section 1371 of the KnoxKeene Act requires PacifiCare to bear the ultimate responsibility for the payment of claims despite its capitation agreement with DPA. At the time this action was instituted, section 1371 provided in full: “A health care service plan, including a specialized health care service plan, shall reimburse [787]*787claims or any portion of any claim, whether in state or out of state, as soon as practical, but no later than 30 working days after receipt of the claim by the health care service plan, or if the health care service plan is a health maintenance organization, 45 working days after receipt of the claim by the health care service plan, unless the claim or portion thereof is contested by the plan in which case the claimant shall be notified, in writing, that the claim is contested or denied, within 30 working days after receipt of the claim by the health care service plan, or if the health care service plan is a health maintenance organization, 45 working days after receipt of the claim by the health care service plan. The notice that a claim is being contested shall identify the portion of the claim that is contested and the specific reasons for contesting the claim.

“If an uncontested claim is not reimbursed by delivery to the claimants’ address of record within the respective 30 or 45 working days after receipt, interest shall accrue at the rate of 10 percent per annum beginning with the first calendar day after the 30- or 45-working-day period.

“For the purposes of this section, a claim, or portion thereof, is reasonably contested where the plan has not received the completed claim and all information necessary to determine payer liability for the claim, or has not been granted reasonable access to information concerning provider services. Information necessary to determine payer liability for the claim includes, but is not limited to, reports of investigations concerning fraud and misrepresentation, and necessary consents, releases, and assignments, a claim on appeal, or other information necessary for the plan to determine the medical necessity for the health care services provided.

“If a claim or portion thereof is contested on the basis that the plan has not received all information necessary to determine payer liability for the claim or portion thereof and notice has been provided pursuant to this section, then the plan shall have 30 working days or, if the health care service plan is a health maintenance organization, 45 working days after receipt of this additional information to complete reconsideration of the claim.

“The obligation of the plan to comply with this section shall not be deemed to be waived when the plan requires its medical groups, independent practice associations, or other contracting entities to pay claims for covered services.” (Italics added.)

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94 Cal. App. 4th 781, 114 Cal. Rptr. 2d 623, 2001 Daily Journal DAR 13143, 2001 Cal. Daily Op. Serv. 10586, 2001 Cal. App. LEXIS 2930, Counsel Stack Legal Research, https://law.counselstack.com/opinion/desert-healthcare-district-v-pacificare-fhp-inc-calctapp-2001.