ZEMBSCH v. Superior Court

53 Cal. Rptr. 3d 69, 146 Cal. App. 4th 153
CourtCalifornia Court of Appeal
DecidedJanuary 11, 2007
DocketA114157
StatusPublished
Cited by43 cases

This text of 53 Cal. Rptr. 3d 69 (ZEMBSCH 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
ZEMBSCH v. Superior Court, 53 Cal. Rptr. 3d 69, 146 Cal. App. 4th 153 (Cal. Ct. App. 2007).

Opinion

Opinion

GEMELLO, J.

In the unpublished part of our opinion, we consider whether Health Net met its burden of proving the existence of an arbitration agreement applicable to the Zembschs’ claims. We hold that Health Net did not meet its burden of proving the existence of an arbitration agreement for the years 2002 through *157 2004. We do not decide whether Health Net met its burden of proving an applicable agreement in 2005 because the arbitration disclosure signed by Mark Zembsch does not comply with section 1363.1, subdivision (b).

Factual and Procedural Background

Although the parties offer sharply divergent versions of the facts surrounding the Zembschs’ underlying claims, the Zembschs’ petition for writ of mandate seeks review only of the trial court order compelling them to arbitrate. The facts relevant to the issue of arbitrability, and thus to our disposition of this writ petition, are largely undisputed. We summarize these facts below.

The Health Net Plan

Petitioner Mark Zembsch is an attorney employed by the City of Berkeley (the City). As an employee of the City, Zembsch and his family were eligible for group health insurance coverage under a group hospital and professional service agreement between the City and Health Net of California, Inc. (Health Net). On May 9, 2002, Zembsch signed a form enrolling himself, his wife, and his two children in a Health Net plan. The plan Zembsch elected provided health maintenance organization (HMO) coverage. With this type of coverage, most services are provided by or coordinated with a member’s primary care physician and a contracting physician group. Alta Bates Medical Group (Alta Bates) is the physician group that, in contract with Health Net, provides medical care to the Zembsch family.

Although the plan contemplates that most medical care will be provided by the contracting physician group, Health Net’s plan permits members to receive a “standing referral” to a specialist. Such a referral allows a member to see a specialist without receiving a specific referral from the member’s primary care physician for each visit. A standing referral is authorized by the plan if it is determined to be necessary by the primary care physician, Health Net’s medical director, and the member.

The Health Net Enrollment Form

The enrollment form that Zembsch signed when he joined the Health Net plan is a one-page document entitled “Member Enrollment and Change Form.” 2 Most of the form is a series of blank spaces in which the enrollee fills in personally identifying information. The blanks appear in four boxes *158 separated by boldface black lines. Beneath a boldface black line at the very bottom of the page are two single-spaced, unindented “paragraphs” printed in the smallest typeface used on the form. 3 The first and longer of these two paragraphs concerns the enrollee’s authorization for the release of medical information. Immediately above the signature line the following paragraph appears: “Arbitration Agreement: I understand that any dispute or controversy, except medical malpractice, that may arise regarding the performance, interpretation or breach of the agreement between myself (and/or any enrolled family member) and Health Net, Health Net Life Insurance Company or any Participating Physician Group/Independent Physicians Association, whether arising in contract, tort or otherwise, must be submitted to arbitration in lieu of a jury or court trial. Please sign and date this application below. Your signature indicates that you have completed all requested information as accurately as possible and understand all agreements implied including your agreement to submit disputes to binding arbitration.”

The Dispute Over a Standing Referral

The Zembschs’ five-year-old son, Jack, suffers from a life-threatening condition known as metatropic dysplasia. Metatropic dysplasia is an extremely rare form of dwarfism characterized by shortened limbs and a badly deformed spine. Jack suffers from multiple orthopedic problems including severe kyphoscoliosis, torticollis, and hip flexion contracture. The small thoracic cavity and stiff chest wall resulting from the condition cause severe restrictive lung disease and can result in cardiopulmonary compromise later in life. Children afflicted with metatropic dysplasia may require tracheotomy and ventilator support. The severity of the condition increases as Jack’s skeleton grows, which adds urgency to this writ proceeding.

Given the rarity of Jack’s condition, there are very few physicians with any substantial experience in treating it. As a consequence, in August 2004 the Zembschs sought a standing referral to Dr. William G. Mackenzie at the Alfred I. duPont Hospital for Children in Wilmington, Delaware. According to the Zembschs’ primary care physician, Dr. Mackenzie is recognized as the leading expert in the treatment of metatropic dysplasia. Alta Bates denied the Zembschs’ request because Dr. Mackenzie was an out-of-network provider and Alta Bates determined that the services requested were available “within the Alta Bates Medical Group Network.” The Zembschs then filed a number of appeals of Alta Bates’s decision, all of which were denied by Health Net.

*159 The Zembschs’ Action Against Health Net and Alta Bates

On November 7, 2005, the Zembschs filed an action against Health Net and Alta Bates in the Superior Court of Alameda County. Two days later, Health Net issued a standing referral for Jack Zembsch to obtain ongoing consultations with Dr. Mackenzie. According to the Zembschs, this standing referral was inadequate because it was for consultation only.

The Zembschs then filed a first amended complaint on December 5, 2005, alleging breach of contract and a number of other causes of action arising out of defendants’ alleged refusal to honor their obligations under the Health Net plan. Both Health Net and Alta Bates moved to compel arbitration and stay the action. Petitioners opposed the motions by raising various defenses.

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Cite This Page — Counsel Stack

Bluebook (online)
53 Cal. Rptr. 3d 69, 146 Cal. App. 4th 153, Counsel Stack Legal Research, https://law.counselstack.com/opinion/zembsch-v-superior-court-calctapp-2007.