Judge: Mark E. Windham, Case: 21CHLC14360, Date: 2023-01-03 Tentative Ruling
Case Number: 21CHLC14360 Hearing Date: January 3, 2023 Dept: 26
Advanced Orthopedic Center, Inc. v. United Life Insurance Company, et al.
MOTION
FOR SUMMARY JUDGMENT
(CCP §
437c)
TENTATIVE RULING:
Defendant Unified Life Insurance
Company’s Motion for Summary Judgment is GRANTED.
DEFENDANT IS TO FILE A PROPOSED
JUDGMENT WITHIN 10 DAYS OF THIS ORDER.
ANALYSIS:
Plaintiff Advanced
Orthopedic Center, Inc. (“Plaintiff”) brought
this action for quantum meruit and breach of implied contract against Defendant
Unified Life Insurance Company (“Defendant”) on
April 13, 2021. Defendant filed an Answer on June 9, 2021. On October 26, 2021,
the action was reassigned to the Limited Jurisdiction Court.
On October 10, 2022, Defendant filed the instant Motion for
Summary Judgment. Plaintiff filed an opposition on December 8, 2022.
Discussion
The Complaint alleges causes
of action for quantum meruit and breach of implied contract based on the
following facts. Plaintiff is a provider of medical services and provided said
services to Defendant’s members, subscribers and insureds. (Compl., ¶¶2-3.) By
providing this treatment, Plaintiff became entitled to payment, reimbursement
or indemnification from Defendant. (Id. at ¶3.) Plaintiff submitted
claims and billings for these services to Defendant, and exhausted all required
administrative appeals, but Defendant continues to refuse to make full payment
and/or substantially underpaid for the services (Id. at ¶¶4, 23.)
Defendant is licensed by the DHMC and/or Department of Insurance to transact
the business of insurance in this state and therefore is subject to the law and
regulations of this state. (Id. at ¶5.) Plaintiff provided medical
services to a specific patient (hereinafter “the Patient”), who was an insured,
member, policy-holder, certificate-holder, or otherwise covered under policies
or certificates of insurance underwritten by Defendant. (Id. at ¶¶8-10.)
Defendant received or continues to receive premium payments or other valuable
consideration from the Patient subject to the applicable policies. (Id.
at ¶11.) As an out-of-network provider, Plaintiff is entitled to receive
payment based on its billed or total charges for the services provided to the
Patient. (Id. at ¶¶14-16.) Plaintiff was legally obligated to provide
the medical services to the Patient because the services the Patient required
were either emergent or post-stablization. (Id. at ¶17.)
Defendant moves for summary judgment on the Complaint
pursuant to Code of Civil Procedure section 437c. A defendant seeking summary
judgment must show either (1)
that one or more elements of the cause of action cannot be established; or (2) that there is a complete
defense to that cause of action. (Code Civ. Proc., § 437c, subd. (p)(2).)
Plaintiff is under no evidentiary burden to produce rebuttal evidence until
Defendant meets its initial moving burden. (Binder v. Aetna Life Insurance
Company (1999) 75 Cal.App.4th 832, 839-840.)
Request for Judicial Notice
In support of the Motion, Defendant requests that the court
take judicial notice of (1) Benjamin Gerendash’s Claim and Order to Go to Small
Claims Court, filed December 1, 2020; (2) the Small Claims Court’s Minute Order
on Gerendash’s claims against Unified, entered on March 23, 2021; (3)
Gerendash’s Request to Correct or Cancel Judgment and Answer, filed on March
23, 2021; (4) the Small Claims Court’s Order on Gerendash’s Request to Correct
or Cancel Judgment and Answer, entered on April 15, 2021; and (5) the Small
Claims Court’s Minute Order on Gerendash’s Request to Correct or Cancel
Judgment and Answer, entered on January 13, 2022. The request is made pursuant
to Cal. Evidence Code section 452, subdivision (d).
Defendant misunderstands the scope of judicial notice of
court records, which explained in detail by the Court of Appeals:
Judicial notice is properly taken of
the existence of a factual finding in another proceeding, but not of the truth
of that finding. (Fowler v. Howell (1996) 42 Cal.App.4th 1746, 1749, 50
Cal.Rptr.2d 484; Evid.Code, §§ 452, subds. (c) & (d), 459, subd. (a); 1
Witkin, Cal. Evidence (4th ed. 2000) Judicial Notice, § 24, pp. 118–119.) “A
court may take judicial notice of [another] court’s action, but may not use it
to prove the truth of the facts found and recited. [Citations.]” (O'Neill v.
Novartis Consumer Health, Inc. (2007) 147 Cal.App.4th 1388, 1405, 55
Cal.Rptr.3d 551, italics added.) As our Supreme Court explained, judicial
notice of findings of fact does not mean that those findings of fact are true;
it means only that those findings of fact were made. (Professional Engineers v.
Department of Transportation (1997) 15 Cal.4th 543, 590, 63 Cal.Rptr.2d 467,
936 P.2d 473.) “ ‘[N]either a finding of fact made after a contested adversary
hearing nor a finding of fact made after any other type of hearing can be
indisputably deemed to have been a correct finding....’ ” (Ibid.)
(Steed v. Department of Consumer Affairs (2012) 204
Cal.App.4th 112, 120-121.) Therefore, Defendant’s request for judicial notice
of these court records is denied because the existence of the factual findings
therein is not relevant to this action, nor is the truth of the findings a
proper subject of judicial notice.
Cause of Action for Quantum Meruit
The elements of a cause of action for quantum meruit are “(1)
the plaintiff acted pursuant to ‘an explicit or implicit request for the
services’ by the defendant, and (2) the services conferred a benefit on the
defendant.” (Port Medical Wellness, Inc. v. Connecticut General Life
Insurance Company (2018) 24 Cal.App.5th 153, 180 [citing Day v. Alta
Bates Medical Center (2002) 98 Cal.App.4th 243, 249].) Said alternatively,
the party “must show the circumstances were such that ‘the services were
rendered under some understanding or expectation of both parties that
compensation therefor was to be made.’” (Chodos v. Borman (2014) 227
Cal.App.4th 76, 96 [citing Estate of Mumford (1916) 173 Cal. 511, 523].)
Defendant presents the following facts in support of its
contention that there was no understanding or expectation regarding
compensation for services provided to the Patient. Dr. Jonathon Nissanoff
provided medical treatment to the Patient on February 25, 2020. (Motion,
Separate Statement, Fact Nos. 1-4; Dill Decl., Exhs. 1-2; Brown Decl., ¶4.) The
services were submitted to Defendant as Claim Nos. 20200429E000087 and
20200424E001027, for total billings of $21,185.80. (Motion, Separate Statement,
Fact Nos. 1-4; Dill Decl., ¶14 and Exhs. 1-4.) The Patient is insured under
Defendant’s Group Accident and Sickness Fixed Indemnity Health Insurance Policy
(“the Fixed Policy”). (Motion, Separate Statement, Fact No. 5; Dill Decl., Exh.
4.) Plaintiff did not attempt to obtain authorization for the medical services
provided to the Patient on or before the alleged date of service, February 25,
2020, as demonstrated by Defendant’s call logs. (Motion, Separate Statement,
Fact Nos. 7-8; Dill Decl., Exh. 3.) The call logs only show a call from
Plaintiff about the services provided weeks after the date of service. (Motion,
Separate Statement, Fact No. 8; Dill Decl., Exh. 3.) It also shows a call on
February 28, 2020 regarding a different claim, which is not the subject to this
action. (Motion, Separate Statement, Fact No. 8; Dill Decl., Exh. 3.) Defendant
received an appeal from Plaintiff with respect to the services provided on
February 25, 2020, which it denied on the grounds that those services were not
covered by the Patient’s insurance plan. (Motion, Separate Statement, Fact Nos.
9-12, 16-26; Dill Decl., Exhs. 4, 7-8.)
This evidence carries Defendant’s
initial burden of proof regarding Plaintiff’s inability to demonstrate the
necessary elements of the quantum meruit claim, namely that Defendant made a
request for the medical services provided to the Patient, or that the parties
had some understanding or expectation that Defendant would compensate Plaintiff
for the medical services provided to the Patient. Likewise, the evidence shows
that Defendant did not receive a benefit as a result of Plaintiff’s provision
of medical services to the Patient because the Patient’s Fixed Policy expressly
excludes those services.
The burden now shifts to
Plaintiff to demonstrate the existence of a triable issue of material fact
regarding such a request and/or understanding of compensation. In opposition,
Plaintiff disputes that there was no request for authorization prior to
providing medical services to the Patient. Plaintiff contends its Emergency
Room representative, “Liz” made a call to Defendant’s representative, “Brian”
who stated that prior authorization was not required for emergency room
services to be rendered to the Patient. (Opp., Separate Statement, Fact Nos. 7,
15-18, 20-26; Gerendash Decl., ¶¶4-5; Nissanoff Decl., ¶¶4-6, 8-9.) The
evidence of this call by Liz to Brian is set forth in the declarations of
Benjamin Gerendash, a nurse practitioner, and Jonathan Nissanoff, MD, a
physician, who provided the subject services to the Patient on February 25,
2020.
Gerendash and Nissanoff’s
declarations, however, only provide inadmissible hearsay accounts of the
purported phone call from Plaintiff’s emergency department to Defendant. (Opp.,
Gerendash Decl., ¶¶4-5; Nissanoff Decl., ¶¶4-5.) No declaration based on
personal knowledge, nor admissible documentary evidence, is provided to support
that any call was made from Plaintiff to Defendant on February 25, 2020, or at
any time before the medical services at issue were rendered to the Patient. Plaintiff,
therefore, has not set forth admissible evidence in support of its contentions,
as required by the summary judgment statute. (See Code Civ. Proc., § 437c,
subd. (d) [“Supporting and opposing affidavits or declarations shall be made by
a person on personal knowledge, shall set forth admissible evidence, and shall
show affirmatively that the affiant is competent to testify to the matters
stated in the affidavits or declarations.”].) Plaintiff also argues that it
made a call on February 28, 2020 that affirmed the earlier conversation between
“Liz” and “Brian” on February 25, 2020. (Opp., Chin Decl., Exh. 1, p. 2.) However,
Plaintiff’s call log does not demonstrate that the call on February 28, 2022
affirmed an earlier authorization or was about the claims that are the subject
of this action. (Ibid.)
Plaintiff’s evidence, therefore,
does not overcome Defendant’s showing regarding the lack of any request by
Defendant to perform the medical services at issue, or the lack of any understanding
or expectation that Defendant would compensate Plaintiff for the medical
services provided to the Patient. Nor has Plaintiff overcome the lack of any
benefit to Defendant. Plaintiff simply disputes the evidence of what services were
covered by the Fixed Policy by repeatedly citing to Gerendash and Nissanoff’s
declarations regarding the purported prior authorization. (Opp., Separate
Statement, Fact Nos. 15-26; Gerendash Decl., ¶¶4-5; Nissanoff Decl., ¶¶4-6,
8-9.) As already discussed, these declarations do not overcome Defendant’s
evidence. Finally, to the extent Plaintiff makes objections to the contents of
Defendant’s separate statement, these are improper because they do not address
specific evidence, which is the purpose of evidentiary objections. Nor are the
objections in the format required by Cal. Rules of Court 3.1354.
Breach of Implied Contract
The parties do not specify if
this cause of action is for breach of implied-in-fact contract or breach of
implied-in-law contract. However, the allegations of the Complaint only support
an action for breach of implied-in-law contract. “[A]n implied-in-law contract
or quasi-contract is not based on the intention of the parties, but arises from
a legal obligation that is imposed on the defendant.” (Unilab Corp. v.
Angeles-IPA (2016) 244 Cal.App.4th 622, 639.) The elements are: (1)
Defendant used for its benefit property of plaintiff; (2) in such manner and
under circumstances that the law will impose a duty of compensation therefore.
(Weitzenkorn v. Lesser (1953) 40 Cal.2d 778, 794.) Here, Plaintiff
alleges that it was required by law to treat the Patient and Defendant was
required by law to reimburse Plaintiff for the services provided at the usual,
customary, and reasonable rate for those services. (Compl., ¶53.)
Defendant presents evidence that
it is part of the “MultiPlan Limited Benefit Plan” which provides discounts for
services that are covered by the Limited Policy. (Motion, Separate Statement,
Fact No. 26; Dill Decl., Exh. 6.) However, Defendant again points out the
limited scope of the Fixed Policy with respect to coverage of medical services,
which does not cover the services at issue in the subject claims. (Motion,
Separate Statement, Fact Nos. 41-50; Dill Decl., Exhs. 4, 8.) Its participation
in “MultiPlan” does not change what services are covered, rather it simply
provides discounts for covered services. (Motion, Separate Statement, Fact No.
26; Dill Decl., Exh. 6.) Defendant further provides evidence that the Fixed
Policy was approved by the Department of Insurance without any requirement that
Defendant cover the costs associated with the medical services at issue in this
action. (Motion, Separate Statement, Fact No. 55; Dill Decl., Exh. 8; Brown
Decl., Exh. 2.) This carries Defendant’s initial burden of proof that it was
under no obligation imposed by law to pay for medical services rendered that
were beyond the scope of the Limited Policy.
In opposition, Plaintiff argues
that under the Limited Policy, the Patient was authorized to seek care with
“Multiplan” contracted doctors, of which Dr. Nissanoff is one such contracted
provider. (Opp., Separate Statement, Additional Fact Nos. 8-9; Nissanoff Decl.,
¶¶8-9 and Exh. 2.) Specifically, “MutliPlain” has agreed to pay Dr. Nissanoff
85 percent of the usual, customary and reasonable fees for services rendered under
that agreement. (Opp., Separate Statement, Additional Fact Nos. 8-9; Nissanoff
Decl., ¶9.) This comports with Defendant’s explanation of the “MultiPlan”
agreement but does not show how it changes what medical services were covered
under the Fixed Policy. The effect of the “MutliPlan” agreement, therefore, is
simply to apply a discount to services that are covered. Plaintiff’s evidence
still does not show that the medical services it provided were covered under
the Patient’s Fixed Policy. Therefore, Plaintiff has not demonstrated the
existence of a triable issue of material fact regarding Defendant’s obligation
under the law to pay for the medical services provided to the Patient.
Conclusion
Defendant Unified Life Insurance
Company’s Motion for Summary Judgment is GRANTED.
DEFENDANT IS TO FILE A PROPOSED
JUDGMENT WITHIN 10 DAYS OF THIS ORDER.
Moving party to give notice.