Ochs v. PacifiCare of California

9 Cal. Rptr. 3d 734, 115 Cal. App. 4th 782, 2004 Cal. Daily Op. Serv. 1220, 2004 Daily Journal DAR 1499, 2004 Cal. App. LEXIS 157
CourtCalifornia Court of Appeal
DecidedFebruary 9, 2004
DocketB160624
StatusPublished
Cited by43 cases

This text of 9 Cal. Rptr. 3d 734 (Ochs v. PacifiCare of California) 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
Ochs v. PacifiCare of California, 9 Cal. Rptr. 3d 734, 115 Cal. App. 4th 782, 2004 Cal. Daily Op. Serv. 1220, 2004 Daily Journal DAR 1499, 2004 Cal. App. LEXIS 157 (Cal. Ct. App. 2004).

Opinion

Opinion

COFFEE, J.—

Health and Safety Code section 1371.4 1 generally requires health care service plans to pay for emergency medical care rendered to their enrollees, regardless of whether the provider rendering the services has contracted with the plan. Subdivision (e) of that section provides, “A health care service plan may delegate the responsibilities enumerated in this section to the plan’s contracting medical providers.” Here we conclude that a health care service plan is not statutorily obligated to pay for emergency services when it has delegated its payment responsibilities to a contracting medical provider that becomes insolvent and is unable to pay. It may, however, be hable to pay for emergency services when it has acted negligently in delegating its payment responsibilities.

FACTS AND PROCEDURAL HISTORY

According to allegations in its first amended complaint, plaintiff and appellant Melvin A. Ochs, M.D., Medical Corporation (Ochs), is a professional corporation that provides emergency room services at Scripps Memorial Hospital in Chula Vista, California. Defendants and respondents PacifiCare of California and PacifiCare of California dba Secure Horizons (collectively PacifiCare) are health care service plans licensed by the State of California under the Knox-Keene Health Care Services Plan Act (KnoxKeene Act) (§ 1340 et seq.).

Health care service plans such as PacifiCare do not actually provide medical services and generally contract for such services with intermediaries such as medical groups and independent practice associations. PacifiCare *788 contracted with the independent practice association Family Health Network (FHN) to provide health care services to its enrollees who chose FHN as their medical provider. Some of these enrollees live in the vicinity of Scripps Memorial Hospital and rely upon Ochs for emergency services. Ochs does not have a contract with either PacifiCare or FHN to provide medical care to their enrollees, but emergency care providers are required by both state and federal law to provide emergency services without regard for a patient’s ability to pay. (§ 1317; 42 U.S.C. § 1395dd.)

The contract between PacifiCare and FHN purports to delegate PacifiCare’s responsibility for providing medical services to FHN. Ochs provided emergency services to PacifiCare enrollees covered by FHN and submitted the bills for those services to FHN, but FHN has declared bankruptcy and is unable to pay those bills. Ochs sought payment from PacifiCare directly, which has declined to pay the bills on the ground that it is not financially responsible for services delegated to FHN.

Ochs filed suit against PacifiCare, alleging causes of action for statutory violations of the Knox-Keene Act, unfair business practices, negligence, declaratory and injunctive relief regarding PacifiCare’s continuing obligation to pay for emergency services provided to PacifiCare/FHN enrollees, common counts for services rendered, quantum meruit, breach of contract as a third party beneficiary, and declaratory relief regarding Ochs’s right to directly bill patients. PacifiCare filed a demurrer to Ochs’s first amended complaint, arguing that it had delegated its responsibilities to FHN and was not obligated to pay for noncontract emergency services provided to enrollees who had selected FHN as their medical care provider. The trial court agreed, sustained the demurrer without leave to amend, and entered a final judgment of dismissal. Ochs appeals.

DISCUSSION

Order Sustaining Demurrer

When reviewing an order sustaining a demurrer, we review the trial court’s ruling de novo, exercising our independent judgment to determine whether the complaint states a cause of action under any legal theory. (Trader Sports Inc. v. City of San Leandro (2001) 93 Cal.App.4th 37, 43-44 [112 Cal.Rptr.2d 677].) We accept as true the properly pleaded allegations of facts in the complaint, but not the contentions, deductions or conclusions of fact or law. (Blank v. Kirwan (1985) 39 Cal.3d 311, 318 [216 Cal.Rptr. 718, 703 P.2d 58].)

*789 1. Statutory Violations of Knox-Keene Act

Section 1371.4 is the portion of the Knox-Keene Act governing compensation for emergency care services. Subdivision (b) of that statute requires health care service plans to pay for emergency care rendered to their enrollees regardless of whether the emergency care provider is under contract with the plan: “A health care service plan shall reimburse providers for emergency services and care provided to its enrollees, until the care results in the stabilization of the enrollee .... As long as federal or state law requires that emergency services and care be provided without first questioning the patient’s ability to pay, a health care service plan shall not require a provider to obtain authorization prior to the provision of emergency services and care necessary to stabilize the enrollee’s emergency medical condition.” Subdivision (e) provides, “A health care service plan may delegate the responsibilities enumerated in this section to the plan’s contracting medical providers.”

In its second cause of action for statutory violations, Ochs contends that PacifiCare had a mandatory duty to pay for emergency services provided to PacifiCare enrollees under section 1371.4, subdivision (b). Ochs also argues that under sections 1371 and 1371.35, subdivision (f), PacifiCare’s duty to pay for services cannot be waived. PacifiCare responds that its delegation of its duties to FHN under section 1371.4, subdivision (e) absolved it of financial responsibility for claims that FHN was unable to pay.

The legal effect of a delegation under section 1371.4, subdivision (e) was recently addressed in California Emergency Physicians Medical Group v. PacifiCare of California (2003) 111 Cal.App.4th 1127 [4 Cal.Rptr.3d 583] (Emergency Physicians). Emergency Physicians concluded that a health care service plan does not remain liable for emergency care claims when the responsibility for those claims has been delegated to a contracting medical provider such as FHN under section 1371.4, subdivision (e). The court reasoned that when a duty held by a licensee such as a medical plan is deemed to be nondelegable, the licensee remains liable for the nonperformance of its agents. (Emergency Physicians, at p. 1132.) “Because a licensee like PacifiCare remains liable for a nondelegable duty, when the Legislature used the term ‘delegate’ in subdivision (e), it must have intended that the obligations of section 1371.4 are delegable duties; that is, duties for which the health care service plan does not retain liability.” (Ibid.)

We find this reasoning persuasive. A “delegation” is commonly understood to mean the “transfer of authority by one person to another, which may infer a general power to act for another’s benefit or which may assign a debt to another.” (Barron’s Law Diet. (2d ed. 1984), p.

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9 Cal. Rptr. 3d 734, 115 Cal. App. 4th 782, 2004 Cal. Daily Op. Serv. 1220, 2004 Daily Journal DAR 1499, 2004 Cal. App. LEXIS 157, Counsel Stack Legal Research, https://law.counselstack.com/opinion/ochs-v-pacificare-of-california-calctapp-2004.