 |
 |
to fill out a simple form to connect to Personal Injury Lawyers in your area.
|
|
|
|
|
Levy v. PacifiCare of California12/22/1999
APPEAL from the Superior Court of Riverside County. Douglas P. Miller, Judge. Affirmed.
Plaintiff Gilbert Levy appeals from an adverse judgment entered after defendants' demurrers to the first amended complaint were sustained without leave to amend. The complaint contains nine causes of action, all based upon plaintiff's claim that he was wrongfully denied access to a second medical opinion concerning a cancer diagnosis and was then denied coverage for corrective surgery. The trial court found it lacked jurisdiction to hear plaintiff's claims since he failed to exhaust administrative remedies mandated by the Medicare Act. (42 U.S.C. ยง 1395 et seq.) Plaintiff asserts none of his causes of action were subject to administrative review and therefore the trial court erred. We disagree with the plaintiff and affirm.
Facts and Procedural History
Plaintiff filed his original complaint on June 10, 1997. In response, PacifiCare of California, doing business as Secure Horizons, and PacifiCare Health Systems, Inc. (collectively PacifiCare), filed a notice of removal to federal court. The parties later stipulated to remand the case to superior court. Both PacifiCare and Empire Physicians Medical Group (Empire) (collectively Defendants) demurred. The court overruled both demurrers as to certain causes of action and sustained the demurrers as to other causes of action, with leave to amend.
On November 26, 1997, plaintiff filed a first amended complaint including nine causes of action against PacifiCare and Empire. Plaintiff alleges: The Department of Labor through the Health Care Financing Agency (HCFA) contracts with health maintenance organizations (HMO's) including PacifiCare, to provide medical care to Medicare-eligible senior and disabled citizens. In Southern California, HCFA pays the HMO approximately $570 per month for each enrollee, whether any medical treatment is provided or not. The HMO's must allow dissatisfied members to disenroll at any time, effective on the first of the month following the election. Those members may choose another HMO or the standard Medicare entitlement. Therefore, it is in the best interest of the HMO to enroll healthy persons, and then cause them to be dissatisfied and disenroll as soon as they require significant levels of treatment.
PacifiCare, a provider of medical benefits with duties equivalent to those of an insurance company, contracts with independent doctor groups, such as Empire, to supply medical services to its enrollees. PacifiCare managed and controlled the activities of Empire, and vice versa, as a result of a contract between them by which Empire agreed to provide medical care, benefits determination and utilization review services to PacifiCare insureds. The contractual arrangement between PacifiCare and Empire created a financial disincentive for Empire to refer patients to practitioners or facilities not under contract with PacifiCare. PacifiCare paid Empire according to the number of plan enrollees, not the amount of medical services provided. Further, Empire had to cover the cost of outside referrals for treatment it could not provide. These types of covenants often result in the delay and/or denial of necessary medical care for plan enrollees. PacifiCare required Empire to keep these arrangements a secret from the patients.
PacifiCare was the benefits administrator and underwriter of a health insurance policy issued to plaintiff as an alternative to the Medicare program. Prior to his enrolling, PacifiCare represented to plaintiff that he would be entitled to everything Medicare offered and more, would be able to choose his own primary care physician and would be entitled to all treatm
Page 1 2 3 4 5 6 7 8 California Personal Injury Attorneys
Personal Injury Lawyers
|
| |
to fill out a simple form to connect to Personal Injury Lawyers in your area.
|
|