Ochs v. Pacificare of California

Health Plan Reimbursement

Ochs
v. Pacificare of California,
2d Civ. No. B160624 (Cal. Ct. App. Feb. 9, 2004)

The California Court of Appeal held that a health plan that
delegates, to a health care provider, its statutory duty to pay for emergency
services that are provided to its enrollees is not required to pay for those
services if the provider becomes insolvent or unable to pay. Accordingly, the
court sustained a demurrer in favor of a health care service plan that was sued
by a physician group that provided emergency care to enrollees of the plan,
but was unable to collect its fees from the enrollees’ provider. However, the
court granted the physician group leave to amend its complaint, holding that
the group could prevail on a claim of negligence if the group could prove that
the health plan contracted with the health care provider when it knew or should
have known that the provider was insolvent.