Justia California Court of Appeals Opinion Summaries

Articles Posted in Health Law
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The Court of Appeal reversed the district court's grant of summary judgment in favor of Aetna. In plaintiff's first cause of action, plaintiff alleged that Aetna violated Health & Safety Code section 1371.4. In plaintiff's second cause of action, plaintiff alleged that Aetna breached an implied contract based on its prior dealing with Aetna by not paying for the emergency medical services it rendered to a patient covered by Aetna's health care service plan. The court held that there were triable issues of fact as to whether plaintiff provided and billed for emergency services and was entitled to reimbursement from Aetna. Accordingly, the court remanded for further proceedings. View "San Jose Neurospine v. Aetna Health of California, Inc." on Justia Law

Posted in: Contracts, Health Law
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The Court of Appeal affirmed the trial court's grant of summary judgment for defendant, a managed care health plan that provides health coverage to low-income individuals under Medi-Cal. The court held that the legislative history of Welfare and Institutions Code section 14105.28, along with the statement of legislative intent within the statute itself, indicate that the Legislature intended the APR-DRG (All Patient Refined Diagnosis Related Group) rates to apply to out-of-network inpatient poststabilization services under Medi-Cal. Consistent with the legislature's intent, the court interpreted the phrase "managed care inpatient days" to refer to services provided pursuant to a managed care contract, that is, in-network services. View "Dignity Health v. Local Initiative Health Care Authority of Los Angeles County" on Justia Law

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Physicians Committee for Responsible Medicine (Physicians Committee) filed a petition for writ of mandate seeking to prohibit local educational agencies Los Angeles Unified School District (LAUSD) and Poway Unified School District (PUSD) from serving processed meats in their schools, and directing them to modify wellness policies to reflect the goal of reducing or eliminating processed meats. The local educational agencies demurred, arguing they were under no statutory obligation to reduce or eliminate processed meat from schools. The trial court granted the demurrers. Physicians Committee appealed, contending the local educational agencies' failure to reduce or eliminate processed meat from schools abused their discretion in developing statutorily-mandated, local wellness policies. After review, the Court of Appeal disagreed and affirmed the judgment. View "Physicians Com. for Responsible etc. v. L.A. Unified School Dist." on Justia Law

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This case arose following the death of Eric, a resident of Chapala House, licensed as a “long-term health care facility” under the Long-Term Care, Health, Safety, and Security Act of 1973 (the Act) - more specifically, as an “[i]ntermediate care facility/developmentally disabled habilitative” (ICF/DD-H). Plaintiff-appellant RSCR Inland, Inc. (ResCare) owned Chapala House. Defendant-appellant California Department of Public Health (the Department) issued a citation and imposed a civil penalty on ResCare in connection with Eric’s death, and ResCare brought this lawsuit to challenge the citation and penalty. The Court of Appeal addressed the scope of the “reasonable licensee defense” through which a California long-term health care facility could show that a citation for a regulatory or statutory violation should be dismissed, even though there was a factual basis for the citation. The Department argued the defense was available only in the event of an “emergency” or “special circumstances.” The Court of Appeal rejected that view, holding that the facility may succeed in dismissing a citation by demonstrating that it did what might reasonably be expected of a long-term health care facility licensee, acting under similar circumstances, to comply with the regulation or statute that allegedly was violated. “This standard differs from the required showing of due care in a typical negligence case because the facility must show reasonable care directed at complying with the regulation or statute, not reasonable conduct in general. But the standard does not require an emergency or an unusual circumstance.” Applying the statutory standard, the Court concluded substantial evidence supported the trial court’s finding that the facility here had established the reasonable licensee defense. View "RSCR Inland, Inc. v. State Dept. of Public Health" on Justia Law

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The Court of Appeal affirmed the trial court's order reappointing the public guardian of the county as conservator of D.P. under the Lanterman-Petris-Short Act, because D.P. was gravely disabled as a result of a mental disorder. In the published portion of the opinion, the court held that the trial court properly instructed the jury using the applicable statutory definition of gravely disabled. View "Conservatorship of D.P." on Justia Law

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Federal law requires that California must pay the counties and their clinics one hundred percent of the cost of a defined list of services for providing Medicare beneficiaries. Furthermore, California's Medi-Cal statute is consistent with the federal requirement. The Clinic filed suit against the State, seeking the full amount the clinic paid to a contractor. The Court of Appeal affirmed the trial court's grant of the Clinic's petition seeking to require the state to pay one hundred percent of the amount the Clinic paid the contractor. View "Tulare Pediatric Health Care Center v. State Department of Health Care Services" on Justia Law

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Minton, a transgender man diagnosed with gender dysphoria, sued under the Unruh Civil Rights Act, Civil Code 51(b), which guarantees “full and equal accommodations, advantages, facilities, privileges, or services in all business establishments of every kind.” Minton’s physician, Dr. Dawson, scheduled Minton's hysterectomy at Mercy, which is part of Dignity Health. Minton told a Mercy nurse that he is transgender. The following day, Mercy notified Dawson that the procedure was canceled. Mercy’s president, Ivie, informed Dawson that she would “never” be allowed to perform Minton's hysterectomy at Mercy because it was “part of a course of treatment for gender dysphoria, as opposed to any other medical diagnosis.” At Ivie's suggestion, Dawson was able to get emergency admitting privileges at Methodist Hospital, a non-Catholic Dignity hospital about 30 minutes away. Dawson performed Minton’s hysterectomy at Methodist three days later. Dignity argued that as a Catholic hospital, Mercy is bound to follow its facially neutral “Ethical and Religious Directives for Catholic Health Care Services” issued by the U.S. Conference of Catholic Bishops, which prohibit direct sterilization and require that bodily and functional integrity be preserved. The court of appeal reversed the dismissal of Minton’s complaint. Without determining the right of Dignity to provide its services in such cases at alternative facilities, the complaint alleges that Dignity initially failed to do so and that the subsequent rectification of its denial, while likely mitigating plaintiff’s damages, did not extinguish his discrimination claim. View "Minton v. Dignity Health" on Justia Law

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Plaintiff-relator Matthew Omlansky, by virtue of knowledge gleaned as a state employee involved with the Medi-Cal program, brought this qui tam action in the name of the State of California alleging that defendant Save Mart Supermarkets (Save Mart) had violated the False Claims Act in its billings to Medi-Cal for prescription and nonprescription medications, charging a higher price than cash customers paid in violation of 2009 statutory provisions capping Medi-Cal charges at a provider’s usual and customary price (“statutory cap”). Per the trial court, the gist of the alleged fraud upon Medi-Cal, Save Mart generally offered a lower price for medications to cash customers, and would also match a lower price that a competitor was offering (although it appears from an exhibit to the complaint that the latter applied only to prescriptions), but did not apply these discounts from its list prices in the billings it submitted to Medi-Cal. The State declined to intervene. The trial court sustained a demurrer to the original complaint because all of the alleged violations occurred during a period when the 2009 statutory cap was subject to a federal injunction. Plaintiff then filed an essentially identical amended complaint. The only significant change was an allegation in paragraph 45 that Save Mart’s billing practices favoring cash customers continued from December 2016 to March 2017 after the expiration of the injunction, specifying six examples of “illegal pricing.” The court sustained Save Mart’s demurrer to this pleading as to two of the six grounds raised, and denied leave to amend. It entered a judgment of dismissal. Plaintiff timely appealed, but the Court of Appeal concurred with the grounds for the trial court’s ruling, thereby affirming dismissal of Plaintiff’s complaint. View "Omlansky v. Save Mart Supermarkets" on Justia Law

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Defendant, a 24-hour skilled nursing facility, appealed an order denying its petition to compel arbitration of claims asserting negligent or willful misconduct, elder abuse, and wrongful death filed against it by decedent’s daughter as successor in interest and individually. The trial court found the successor claims were not arbitrable because no arbitration agreement existed between decedent and defendant, given defendant’s failure to prove daughter had authority to sign the agreement on decedent’s behalf. The court further found the arbitration agreement was unenforceable against daughter individually on grounds of unconscionability. Finding no reversible error, the Court of Appeal affirmed the trial court order. View "Lopez v. Bartlett Care Center, LLC" on Justia Law

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This case presented a narrow issue of whether respondent Michelle Rouillard in her capacity as director of California’s Department of Managed Health Care (Department) violated the California Administrative Procedure Act (APA) when she sent letters to seven health care service plans directing them to comply with California law in their coverage of abortion services. The issue reduced to whether a “voluntary” abortion was a “medically necessary” procedure that health care service plans were required to cover. The letters told the recipients that health care plans could not limit or exclude coverage for termination of pregnancies. Petitioner Missionary Guadalupanas of the Holy Spirit, Inc., claimed that by sending out the letters interpreting “basic health care services” to include abortions, respondent ignored the APA rulemaking process. The Court of Appeal concluded petitioner’s argument set forth a false dichotomy between a “voluntary” service and a “medically necessary” health care service, which health care plans were required to cover under California Code of Regulations, title 28, section 1300.67."This false assumption led petitioner to the flawed conclusion that the Department’s letters were for the purpose of clarifying an ambiguity in the statute, and that compliance with the rulemaking procedures of the APA was necessary." The Court determined the application of the regulation to the facts of this case was unambiguous, and the Department was not required to comply with the APA. View "Missionary Guadalupanas of the Holy Spirit v. Rouillard" on Justia Law