Wednesday, March 29, 2017
This is a health insurance case, but it's also a case about implied contracts.
In a recent case out of the Eastern District of California, San Joaquin General Hospital v. United Healthcare Insurance Co., No. 2:16-cv-01904-KJM-EFB (behind paywall), the hospital sued the health insurance company after it refused to pay the entirety of the bills the hospital sent to it. The hospital alleged that it had contacted the insurance company to obtain authorizations for the medical services in question and that the insurance company had orally authorized such care. The hospital therefore argued that the two parties had an oral or implied-in-fact contract and the insurance company's refusal to pay the whole bill was a breach of that contract.
The insurance company moved to dismiss the claim but the court disagreed. It found that the complaint alleged the communications I outlined above, and also alleged that the insurance company had paid some of the bill and was refusing to pay the rest. The court found that this partial performance on the part of the insurance company was enough to indicate the presence of an implied-in-fact contract such that the hospital's claim could survive the motion to dismiss.
The hospital also pled a cause of action for quantum meruit, which the insurance company also moved to dismiss, partly on the grounds that the insurance company claimed to receive no benefit from the hospital's actions. The hospital argued in response that it performed services for the insurance company's customers, which thereby benefitted the insurance company. My favorite line of this decision comes during the analysis of this cause of action: "It is plausible on its face that the patients received a benefit from the Hospital's services." Ha. I get why it's phrased that way but it makes me laugh. Maybe. Maybe you got a benefit by being treated for illness or injury by a hospital. Maybe. Seems plausible, at least. Somewhat believable that going to a hospital when ill or injured and receiving services to treat your condition might benefit you in some way.