Pebley v. Santa Clara Organics, LLC

232 Cal. Rptr. 3d 404, 22 Cal. App. 5th 1266
CourtCalifornia Court of Appeal, 5th District
DecidedMay 8, 2018
Docket2d Civ. No. B277893
StatusPublished
Cited by14 cases

This text of 232 Cal. Rptr. 3d 404 (Pebley v. Santa Clara Organics, LLC) is published on Counsel Stack Legal Research, covering California Court of Appeal, 5th District primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Pebley v. Santa Clara Organics, LLC, 232 Cal. Rptr. 3d 404, 22 Cal. App. 5th 1266 (Cal. Ct. App. 2018).

Opinion

PERREN, J.

*406*1268An injured plaintiff with health insurance may not recover economic damages that exceed the amount paid by the insurer for the medical *1269services provided. ( Howell v. Hamilton Meats & Provisions, Inc. (2011) 52 Cal.4th 541, 566, 129 Cal.Rptr.3d 325, 257 P.3d 1130 ( Howell ).) The amount of the "full bill" for past medical services is not relevant to prove past or future medical expenses and/or noneconomic damages. ( Id. at p. 567, 129 Cal.Rptr.3d 325, 257 P.3d 1130 ; Corenbaum v. Lampkin (2013) 215 Cal.App.4th 1308, 1330-1331, 156 Cal.Rptr.3d 347 ( Corenbaum ).) In contrast, the amount or measure of economic damages for an uninsured plaintiff typically turns on the reasonable value of the services rendered or expected to be rendered. ( Bermudez v. Ciolek (2015) 237 Cal.App.4th 1311, 1330-1331, 188 Cal.Rptr.3d 820 ( Bermudez ).) Thus, an uninsured plaintiff may introduce evidence of the amounts billed for medical services to prove the services' reasonable value. ( Id. at pp. 1330-1331, 1335, 188 Cal.Rptr.3d 820.)

Here, we are confronted with an insured plaintiff who has chosen to treat with doctors and medical facility providers outside his insurance plan. We hold that such a plaintiff shall be considered uninsured, as opposed to insured, for the purpose of determining economic damages.

Plaintiff Dave Pebley was injured in a motor vehicle accident caused by defendant Jose Pulido Estrada, an employee of defendant Santa Clara Organics, LLC (Santa Clara). Although Pebley has health insurance, he elected to obtain medical services outside his insurance plan. A jury found defendants liable for Pebley's injuries and awarded him $3,644,000 in damages, including $269,000 for past medical expenses and $375,000 for future medical expenses. For the most part, Pebley recovered the amounts that were billed for past services and expected to be incurred for future services.

We conclude the trial court properly allowed Pebley, as a plaintiff who is treating outside his insurance plan, to introduce evidence of his medical bills. Pebley's medical experts confirmed these bills represent the reasonable and customary costs for the services in the Southern California community. Pebley testified he is liable for these costs regardless of this litigation, and his treating surgeons stated they expect to be paid in full. The court permitted defendants to present expert testimony that the reasonable and customary value of the services provided by the various medical facilities is substantially less than the amounts actually billed, and defendants' medical expert opined that 95% of private pay patients would pay approximately 50% of the treating professionals' bills. The jury rejected this expert evidence and awarded Pebley the billed amounts.

Based on this record, defendants have not demonstrated error except with respect to two charges. It is undisputed the jury improperly awarded Pebley the amounts billed by Ventura County Medical Center (VCMC) and American *1270Medical Response (AMR) instead of the amounts paid to these providers by his insurance carrier. The difference between the amounts billed and the amounts paid is $1,063. We therefore reduce the damage award by that amount and affirm the judgment as modified.

FACTS AND PROCEDURAL BACKGROUND

A. The Accident

On May 9, 2011, Pebley and his wife, Joline, were returning from a camping trip *407in their motor home. Mrs. Pebley was driving eastbound on the 126 freeway in Ventura County when the vehicle developed a flat tire. She turned on the hazard lights, pulled over to the right shoulder and stopped. A portion of the motor home remained in the No. 2 lane.

In the rearview mirror, Mrs. Pebley saw a Kenworth "big rig" truck bearing down on them from behind. The driver, Estrada, who was travelling at approximately 50 miles per hour, crashed into the left rear end of the motor home with sufficient force to break the passenger seat in which Pebley was seated.

The truck, which was owned by Santa Clara, was carrying a 40,000-pound load at the time of the collision. Pebley was transported to the hospital by ambulance, treated and released. He suffered injuries to his face, teeth, neck and lower back.

B. Pebley's Medical Treatment

Pebley initially sought treatment through his health insurance carrier, Kaiser Permanente (Kaiser). After filing a personal injury action against defendants, Pebley obtained care from an orthopedic spine specialist, Dr. Gerald Alexander, who is outside the Kaiser network. Pebley testified he was referred to Dr. Alexander by members of his men's group. Defendants claim Pebley was referred to the doctor by his attorneys. They point to an internet article co-written by one of Pebley's attorneys. The article notes that "[t]ypically, medical liens in personal injury cases have been used where the plaintiff is uninsured, or where the insurance provider will not cover or refuses to authorize recommended medical care." The authors propose, however, that insured plaintiffs use the lien form of medical treatment, which "effectively allows the plaintiff and his or her attorney to sidestep the insurance company and the impact of Howell , Corenbaum and Obamacare." They maintain that treating on a lien basis increases the "settlement value" of personal injury cases. Pebley's post-Kaiser medical treatment was provided on that basis.

*1271Dr. Alexander performed a 3-level cervical fusion surgery on March 13, 2014.1 His co-surgeon was Dr. Carl Lauryssen. At trial, both doctors testified that the injuries Pebley suffered in the accident necessitated the surgery. Dr. Alexander also testified that Pebley would require additional cervical fusion surgery as well as lumbar fusion surgery. Dr.

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Cite This Page — Counsel Stack

Bluebook (online)
232 Cal. Rptr. 3d 404, 22 Cal. App. 5th 1266, Counsel Stack Legal Research, https://law.counselstack.com/opinion/pebley-v-santa-clara-organics-llc-calctapp5d-2018.