Hartenstine v. Superior Court

196 Cal. App. 3d 206, 241 Cal. Rptr. 756, 1987 Cal. App. LEXIS 2323
CourtCalifornia Court of Appeal
DecidedNovember 16, 1987
DocketE003956
StatusPublished
Cited by15 cases

This text of 196 Cal. App. 3d 206 (Hartenstine v. Superior Court) 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
Hartenstine v. Superior Court, 196 Cal. App. 3d 206, 241 Cal. Rptr. 756, 1987 Cal. App. LEXIS 2323 (Cal. Ct. App. 1987).

Opinion

*209 Opinion

McDANIEL, J.

Huntington Intercommunity Hospital (Hospital) sued Stephen Hartenstine (Hartenstine), a federal employee, for $7,709.35 in unpaid hospital expenses. Hartenstine filed a cross-complaint against his insurance carriers, alleging counts in contract and in tort. The trial court granted the carriers’ motion for summary adjudication of the tort counts, on the ground that those counts were preempted by the Federal Employee Health Benefits Act (5 U.S.C. § 8901 et seq., hereafter referred to as FEH-BA). Hartenstine petitioned this court for a writ of mandate which would direct the trial court to vacate its order granting the motion for summary adjudication, and to enter an order denying the motion. We authorized issuance of an alternative writ, the matter is now before us for disposition and we shall deny the petition.

Facts and Proceedings

On August 18, 1980, Hartenstine’s minor daughter Pamela was admitted to Hospital for psychiatric treatment. She was released from Hospital over four months later on December 23, 1980. At the time of her admission, she was covered as a family member under a FEHBA Service Benefit Plan in which her father was enrolled (the Plan). The Plan was administered by Blue Cross of California and Blue Shield of California pursuant to an FEHBA-authorized contract between them and the Office of Personnel Management (OPM). The Plan recited that benefits would not be provided for hospital admissions or portions thereof which, in the judgment of the carriers, had not been medically necessary. The Plan also recited that a denial of a claim would be reconsidered by the local Blue Cross and Blue Shield upon receipt of a written request within one year of the denial, and, within ninety days after an affirmation of the denial, that the claimant could ask OPM to determine if the denial had complied with the provisions of the Plan’s brochure.

In the case here, Blue Cross paid for Pamela’s hospitalization from August 18, 1980, through November 14, 1980, and refused to pay for her hospitalization from November 15, 1980, through December 23, 1980, a total of $7,709.35, on the ground that its review of her records had indicated that the hospitalization after November 14 had not been medically necessary.

Hospital filed suit against Hartenstine for payment of the $7,709.35, plus interest and attorney’s fees. Without, it appears, going through the Plan’s review procedures, ante, Hartenstine filed a cross-complaint against Blue Cross and Blue Shield (the carriers) for breach of contract, breach of the *210 covenant of good faith and fair dealing, and violation of Insurance Code section 790.03, subdivision (h) (unfair claims settlement practices). Under these theories, Hartenstine sought both compensatory and punitive (exemplary) damages.

In his first cause of action for breach of contract, Hartenstine alleged that he was a federal employee and, as such, a beneficiary of the Plan; that the Plan provided for payment of all of Pamela’s hospital expenses, and that the carriers’ refusal to pay her hospital expenses from November 15 through December 23, 1980, constituted a breach of contract. Hartenstine did not attach a copy of the Plan, or any other contract, to his second amended cross-complaint (the pleading as to which the summary judgment was granted). 1

In his second and third causes of action for breach of the covenant of good-faith and fair dealing and violation of Insurance Code section 790.03, subdivision (h), respectively, Hartenstine alleged that the carriers had breached the foregoing covenant and violated the provisions of section 790.03, subdivision (h) by: (a) denying policy benefits to Hartenstine with the knowledge that the denial was contrary to established law and the terms of the policy; (b) refusing to make an adequate or good-faith investigation of Hartenstine’s claim before withholding the benefits; (c) terminating payments during Pamela’s hospitalization without notice or warning to Hartenstine; (d) failing to provide Hartenstine with any reasonable or justifiable basis for the denial of his claim, or with the factual or legal basis for the denial, and (e) consciously applying the policy provisions so as to save money for the carriers and deprive Hartenstine of the benefits rightfully due him.

The carriers each filed an answer to Hartenstine’s second amended cross-complaint. Each of the answers alleged many affirmative defenses, but neither answer alleged, as an affirmative defense, that any of the causes of action in Hartenstine’s cross-complaint were preempted by federal law.

About two years later, Blue Cross noticed a motion for summary adjudication of issues without substantial controversy. In its motion Blue Cross argued, among other things, that Hartenstine’s second cause of action (for breach of the covenant of good faith and fair dealing), his third cause of action (for violation of Ins. Code, § 790.03, subd. (h)), and his requests for damages for emotional distress and for exemplary damages were all *211 preempted by federal law, and that hence Blue Cross was entitled to summary adjudication thereof.

In support of its motion for summary adjudication, Blue Cross attached the declaration of Nora Drain, a consultant in its federal employee program. A copy of the Plan’s 1980 brochure (i.e., the brochure which would have applied to Pamela’s hospitalization, hereafter the Brochure) was attached to the declaration. The declaration recited that it was based upon Dram’s personal knowledge and that she could competently testify that: “. . . [1] 2. At all relevant times Hartenstine was a member of the Plan.

“3. Each year, pursuant to [FEHBA, OPM] publishes, prints and distributes to all federal employees brochures regarding each Federal Employee Health Plan. The brochures are statements of benefits, exclusions and limitations for each Plan.

“4. The [Plan’s brochure] is sent to all federal employees. . . . The provisions of the [Plan] are specifically negotiated each year between Blue Cross and Blue Shield Association and OPM. The OPM must give its approval pursuant to [FEHBA]. Upon approval of the Plan, OPM orders publication of the brochures. . . . OPM then distributes the brochures to the Plan’s subscribers. The Brochure is part of the contract between OPM and Blue Cross and Blue Shield Association.”

Blue Cross’s motion, in compliance with the applicable statute, also included a statement of undisputed material facts. Facts number 4, 5 and 6 reiterated paragraphs 3 and 4 of the Drain declaration, ante, and cited the declaration as the evidentiary source therefor. Fact number 14 recited that Hartenstine had asserted that Blue Cross’s retrospective review of his claims for Pamela’s hospitalization was per se bad faith, and cited, as the evidentiary source therefor, Hartenstine’s notice of motion to vacate an order submitting the case to arbitration. In that motion, Hartenstine had argued that the case should be continued until the California Supreme Court decided Sarchett v. Blue Shield (Cal.App.) *

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Cite This Page — Counsel Stack

Bluebook (online)
196 Cal. App. 3d 206, 241 Cal. Rptr. 756, 1987 Cal. App. LEXIS 2323, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hartenstine-v-superior-court-calctapp-1987.