Kotler v. Pacificare of California

INSURANCE COVERAGE

Kotler v. Pacificare of California, No. B171654 (Cal. Dist.
Ct. App. Feb. 10, 2005)

A patient appealed a trial court decision granting summary judgment for
his health care service plan. The patient claimed a breach of contract due
to his health plan’s delay in providing a specialist to treat his Lyme disease.
The appeals court agreed there was no claim for breach of contract under the "emergency
medical condition" provision of the agreement. However, it did find the
patient had a valid claim due to the unreasonable delay in referring the patient
to a specialist. The court stated the contractual obligation to provide the services
of a specialist must be performed either at the time the contract specifies or
within a reasonable time, and a six-week wait could be found by a jury to be
unreasonable.