UCSF-Stanford Health Care v. Hawaii Management Alliance Benefits & Services, Inc.

58 F. Supp. 2d 1162, 1999 U.S. Dist. LEXIS 11555, 1999 WL 556996
CourtDistrict Court, D. Hawaii
DecidedJuly 22, 1999
DocketCiv. 98-00648DAE
StatusPublished
Cited by3 cases

This text of 58 F. Supp. 2d 1162 (UCSF-Stanford Health Care v. Hawaii Management Alliance Benefits & Services, Inc.) is published on Counsel Stack Legal Research, covering District Court, D. Hawaii primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
UCSF-Stanford Health Care v. Hawaii Management Alliance Benefits & Services, Inc., 58 F. Supp. 2d 1162, 1999 U.S. Dist. LEXIS 11555, 1999 WL 556996 (D. Haw. 1999).

Opinion

*1164 AMENDED ORDER

DAVID ALAN EZRA, Chief Judge.

AMENDED ORDER GRANTING IN PART AND DENYING IN PART DEFENDANTS’ MOTION FOR SUMMARY JUDGMENT

The court heard Defendants’ Motion on July 6, 1999. Alyssa Klausner, Esq., and Peter Lee, Esq., appeared at the hearing on behalf of Plaintiff; Bill Hunt, Esq., and Lea Hong, Esq., appeared at the hearing on behalf of Defendants. After reviewing the Motion and the supporting and opposing memoranda, the court GRANTS in part and DENIES in part Defendants’ Motion for Summary Judgment.

BACKGROUND

This case involves a dispute between an insurer and a health care provider over the insurer’s liability for medical services performed by the health care provider. Plaintiff UCSF-Stanford Health Care (“Plaintiff’) brings this action against Defendants Hawaii Management Alliance Benefits & Services, Inc. and Hawaii Management Alliance Association (“Defendants”), based on Defendants’ refusal to compensate Plaintiff for treatment it provided to a third party, Ye Sun Chon (“Chon”).

On March 25, 1997, Chon completed an Employee Application Form seeking to obtain health insurance from Defendants. In the form, Chon was asked several questions regarding both her employment status and medical history. Chon responded that she was employed by Holiday Shoe Repair (“Holiday”), a company owned by her brother-in-law. Chon also indicated that she was not receiving treatment at the time she completed her application. Defendants contend that Chon’s answers to these questions were false, and were intended to induce Defendants to provide insurance coverage for expensive procedures relating to a brain" tumor she had developed in 1992.

On April 1, 1997, allegedly in reliance on the misrepresentations in Chon’s application, Defendants added Chon to the list of insureds from Holiday. The policy contained specific provisions relating to conditions regarding continuing eligibility as well as termination of coverage. With respect to eligibility, the policy provided that Chon would be entitled to coverage “on the first of the month following a minimum of twenty (20) hours of employment for four (4) consecutive weeks.” The policy further explained that eligibility would continue only if the employee “remains actively working and maintains a minimum of twenty (20) hours of employment per week.”

With respect to termination, the policy provided that “coverage ends the last day of the calendar month in which ... 1. You fail to work at least the required number of hours; 2. You stop working for a Participating Employer; ... 5. You cease actively working as defined in The Plan.” Policy at 8, attached as Exhibit B to Defendants’ Motion for Summary Judgment. The Policy defines “actively working” as “performing all regular duties of ... occupation for a Participating Employer at least seventy (70) hours a month.”

On June 10, 1997, Plaintiff contacted Defendants’ utilization review department, informing them of Chon’s condition and the pending claim for coverage. At that time, during their telephone conversation, Defendants authorized the services to be performed and certified the requested treatment as medically necessary. They then faxed the authorization form to Plaintiff.

On June 18, 1997, Plaintiff again contacted Defendants to confirm Chon’s eligibility for coverage. At that time, Defendants again informed Plaintiff: 1) Chon was an insured and covered by Defendants; 2) Chon was eligible for benefits; 3) Chon’s policy became effective April 1, 1997; 4) Chon had a $2 million lifetime maximum benefit; 5) Chon had a $100 deductible, which had been met; 6) Defendants would pay “80% CTR”; and 7) Chon had an Out-of-Pocket co-payment of $1,500.00, of which $500 had been met. *1165 Again, Defendants did not indicate at anytime during the phone call that Chon’s eligibility was being investigated, and actually affirmatively represented to Plaintiff that there were no pre-existing condition exclusions or limitations on Chon’s policy.

On June 19, 1997, Plaintiff informed Defendants that the scheduled day of treatment had been changed, and Defendants responded by faxing pre-certification forms which indicated that Chon was an insured, and included information regarding deductibles and coverage limits. Also included with the pre-certification forms-were disclaimers regarding the effect of pre-certification:

Pre-Certification is for the sole purpose of reviewing medical necessity of the recommended hospitalization, procedure, treatment, therapy or rehabilitation. Pre-Certification is not a guarantee that charges are covered under the Plan. All charges submitted to [Defendants] are subject to eligibility and all plan provisions, regardless of precertification.

Pre-Certification Forms, attached as Exhibits C & D to Defendants’ Motion for Summary Judgment.

Allegedly in reliance on Defendants’ pre-certification of Chon, on July 1, 1997, Plaintiff admitted Chon for surgery to remove a brain tumor. On June 24 and July 1, 1997, Plaintiff performed two separate brain surgeries, and in August of that year, after a period of recovery, Chon was released. For the services it provided to Chon, Plaintiff submitted interim inpatient bills to Defendants on July 24, 1997, August 4, 1997 and by mail on approximately August 5,1997.

Meanwhile, on July 24,1997, Barbara M. Ornellas, R.N., of Defendants’ Utilization Review Department, informed Plaintiff by facsimile that Chon’s eligibility was being investigated. After conducting its investigation, which allegedly included a review of Plaintiffs own medical records regarding Chon and an interview with Holiday’s owner, Defendants discovered that it had issued the policy based on false representations made by Chon. Specifically, Defendants discovered that Chon had concealed two previous brain surgeries on her application, and had never been an active employee of Holiday. Because Defendants had issued the policy on the basis of Chon’s false representations, Defendants rescinded both Chon’s and Holiday’s coverage and denied Plaintiff the reimbursement it sought for the services it had provided to Chon.

On February 4, 1999, Plaintiff filed its Complaint for damages, alleging five separate causes of action: 1

Count One: Breach of Oral Contract
Count Two: Fraud and Deceit
Count Three: Negligent Misrepresentation
Count Four: Estoppel
Count Five: Quantum Meruit

On March 31, 1999, Defendants filed the instant Motion for Summary Judgment, contending that they are entitled to summary judgment on each of Plaintiffs five claims. Plaintiff filed its Opposition to Defendants’ Motion on May 27, 1999. Defendants filed their Reply on June 3, 1999.

STANDARD OF REVIEW

Rule 56(c) of the Federal Rules of Civil Procedure provides that summary judgment shall be entered when:

...

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Bluebook (online)
58 F. Supp. 2d 1162, 1999 U.S. Dist. LEXIS 11555, 1999 WL 556996, Counsel Stack Legal Research, https://law.counselstack.com/opinion/ucsf-stanford-health-care-v-hawaii-management-alliance-benefits-hid-1999.