Judge Thomas D. Long, Case Number: 23STCV01553, Date: 2024-08-08 Tentative Ruling

On March 8, 2023, Plaintiffs filed a first amended complaint (“FAC”) against only Defendant MedPoint Management.

No. 3: Sustained for lack of foundation and authentication. Declarant is not a party to the emails.

Nos. 1, 2: Denied as unnecessary because the documents are already part of this case’s record.

Defendant is a health care management service organization that provides comprehensive management services, which includes utilization management, care management, and claims processing, for independent practice associations and health care networks. (Undisputed Material Fact “UMF” 1.) It is not a health care service plan and is not an insurer: it does not have patient enrollees, does not insure patients for health care, does not have members, and does not cover patients for health, hospitalization, or medical insurance. (UMF 2.)

The Department of Managed Health Care (“DMHC”) regulates health care service plans under the Knox-Keene Health Care Service Plan Act (“Knox-Keene Act”). (UMF 4.) The DMHC requires all health care service plans in the State of California to be licensed by the DMHC. (UMF 5.) The DMHC maintains a list of all health care service plans in California on its website. (UMF 6.) Defendant is not listed in the DMHC’s list of all health care service plans in California on the DMHC’s website. (UMF 7.)

On January 29, 2021, Plaintiffs provided emergency medical services to Patient CB. (Additional Material Fact “AMF” 1.) Defendant never requested Plaintiffs to provide emergency services to Patient CB. (UMF 8.) Any emergency services that Plaintiffs provided to Patient CB did not benefit Defendant. (UMF 9.)

For each claim in the complaint, the defendant moving for adjudication must satisfy the initial burden of proof by showing that one or more elements of a cause of action cannot be established or that there is a complete defense to a cause of action. (Code Civ. Proc., § 437c, subd. (p)(2); Scalf v. D. B. Log Homes, Inc. (2005) 128 Cal.App.4th 1510, 1520 (Scalf).) Then the burden shifts to the plaintiff to show that a triable issue of material fact exists as to that cause of action or a defense. (Code Civ. Proc., § 437c, subd. (p)(2); Scalf, supra, 128 Cal.App.4th at p. 1520.) To establish a triable issue of material fact, the party opposing the motion must produce “substantial responsive evidence.” (Sangster v. Paetkau (1998) 68 Cal.App.4th 151, 162-163.)

Defendant moves for summary judgment of the sole cause of action for quantum meruit.

Plaintiffs allege that Patient CB was insured by Defendant and paid premiums to Defendant. (FAC ¶ 7.) Plaintiffs submitted a bill for Patient CB’s procedure to Defendant. (FAC ¶ 23.) Plaintiffs allege that Defendant did not comply with the Knox Keene Act when it failed to resolve the billing dispute with Plaintiffs, and Defendant now owes payment for Plaintiffs’ services. (FAC ¶¶ 26-27, 30-34.)

Under the Knox Keene Act, a health care service plan must reimburse providers for emergency services and care provided to its enrollees. (Health & Saf. Code, § 1371.4, subd. (b).) A “health care service plan” is either “(1) Any person who undertakes to arrange for the provision of health care services to subscribers or enrollees, or to pay for or to reimburse any part of the cost for those services, in return for a prepaid or periodic charge paid by or on behalf of the subscribers or enrollees”; or “(2) Any person, whether located within or outside of this state, who solicits or contracts with a subscriber or enrollee in this state to pay for or reimburse any part of the cost of, or who undertakes to arrange or arranges for, the provision of health care services that are to be provided wholly or in part in a foreign country in return for a prepaid or periodic charge paid by or on behalf of the subscriber or enrollee.” (Health & Saf. Code, § 1345, subd. (f).)

Defendant is not an insurer. (UMF 3.) Defendant does not have patient enrollees, does not insure patients for health care, does not have members, and does not cover patients for health, hospitalization, or medical insurance. (UMF 3.) Additionally, the DMHC requires all health care service plans in the State of California to be licensed by the DMHC, and Defendant is not listed in the DMHC’s list of all health care service plans on its website. (UMF 5-6.)

Moreover, “in order to recover under a quantum meruit theory, a plaintiff must establish both that he or she was acting pursuant to either an express or implied request for such services from the defendant and that the services rendered were intended to and did benefit the defendant.” (Day v. Alta Bates Medical Center (2002) 98 Cal.App.4th 243, 248.) Defendant never requested Plaintiffs to provide emergency services to Patient CB, and any emergency services that Plaintiffs provided to Patient CB did not benefit Defendant. (UMF 8-9.)

Defendant has met its burden of showing that it is not a health care service plan subject to the Knox Keene Act and does not owe money to Plaintiffs under a theory of quantum meruit.

Plaintiffs argue, without citing evidence, that “[t]he evidence shows that Defendant engages in the activities that could define Defendant as a health care service plan.” (Opposition at p. 9.) Plaintiffs also note that Chris Macris, Defendant’s Senior Manager of Claims Operations, was confused about the term “health care service plan” during his deposition. (Id. at pp. 8-9.) But this lack of clarity about the term does not negate the factual declarations that Defendant “is not an insurer, does not have patient enrollees, does not insure patients for health care, does not have members, and does not cover patients for health, hospitalization, or medical insurance.” (Macris Decl. ¶ 6.)

Plaintiffs have failed to show the existence of a triable issue of material fact regarding whether Defendant is a health care service plan under the Knox Keane Act and is liable for Plaintiffs’ claim of quantum meruit.

The motion for summary judgment is GRANTED. Defendant is ordered to file a proposed judgment within five days.

A Non-Appearance Case Review Re: Submission of Proposed Judgment is scheduled for August 28, 2024 at 9:00 a.m.

Parties who intend to submit on this tentative must send an email to the Court at SMCDEPT48@lacourt.org indicating intention to submit. If all parties in the case submit on the tentative ruling, no appearances before the Court are required unless a companion hearing (for example, a Case Management Conference) is also on calendar.

Hon. Thomas D. Long

Judge of the Superior Court