Appellate Updates

Dougherty v. U.S. Behavioral Health Plan (Apr. 24, 2024, E079741) ___ Cal.App.5th ___ [2024 WL 1752872]

Christine Matlock Dougherty’s employer entered a Group Subscriber Agreement (GSA) with UnitedHealthcare that included an arbitration provision and made various attachments part of the agreement. Dougherty enrolled herself and her son, Ryan, in a UnitedHealthcare HMO plan by executing an enrollment form that included an arbitration provision meeting the disclosure requirements in Health & Safety Code section 1363.1. Dougherty was given the plan’s Evidence of Coverage (EOC) booklet, which explained that disputes between enrollees and UnitedHealthcare would be arbitrated, and a supplement explaining that U.S. Behavioral Health Plan (USB) would provide substance abuse services. Neither the EOC nor the supplement required Dougherty’s signature. Later, Ryan checked himself into a residential drug treatment facility.

Kime v. Dignity Health, Inc. (Mar. 29, 2024, A166748) __ Cal.App.5th __ [2024 WL 1337210], ordered published April 25, 2024

Dr. Ryan Kime resigned his privileges at a hospital while under investigation, after he was summarily suspended for unilaterally and improperly diverting an emergency room patient to another hospital without performing a medical screening. He also had made an inappropriate gesture toward a nurse. After that hospital filed a Business & Professions Code section 805 report, the Medical Board publicly reprimanded Dr. Kime. 

Ryan S. v. UnitedHealth Group, Inc., __ F.4th __, No. 22-55761, 2024 WL 1561668 (9th Cir. Apr. 11, 2024)

Ryan was a beneficiary of an ERISA group health plan through UnitedHealthcare (UHC). He completed outpatient, out-of-network substance use disorder programs, but UHC did not cover most of those costs. Ryan sued, alleging UHC violated the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (the Parity Act) (29 U.S.C. § 1185a) by using improper internal processes to determine whether outpatient, out-of-network mental health and substance use disorder (MH/SUD) treatment is covered, and violated its fiduciary duty under ERISA, 29 U.S.C. § 1104.

Harrod v. Country Oaks Partners, LLC (Mar. 28, 2024, S276545) ___ Cal.5th ___ [2024 WL 1319134]

Charles Logan executed a power of attorney for health care decisions using a form patterned on the Health Care Decisions Law (Prob. Code, § 4600 et seq.), which authorized his nephew, Mark Harrod, to make “health care” decisions on Logan’s behalf. Logan was later admitted to Country Oaks Care Center to rehabilitate a broken leg. Harrod signed Logan’s admission agreement with Country Oaks, and also signed a separate, nonmandatory agreement requiring arbitration of all legal disputes between Logan and Country Oaks. 

Williams v. Doctors Medical Center of Modesto (March 27, 2024, F084700/F085710) __ Cal.App.5th __ [2024 WL 1298913]

Dr. R. Michael Williams is a board-certified oncologist who practiced at the Doctors Medical Center of Modesto (DMCM). Disagreement over patient care strained the relationship between Dr. Williams and DMCM. Dr. Williams sued, claiming that DMCM improperly curtailed his hospital privileges, limiting his capacity to care for patients. 

Asiryan v. Medical Staff of Glendale Adventist Medical Center (Feb. 29, 2024, B316313) ___ Cal.Rptr.3d ___ [2024 WL 1171035], certified for publication Mar. 19, 2024

Dr. Vardui Asiryan had medical staff privileges at Glendale Adventist Medical Center (GAMC). The GAMC Medical Staff (a separate legal entity from GAMC) is responsible for reviewing physician performance at GAMC to ensure patients receive quality healthcare. After members of the Medical Staff voiced concerns that Dr. Asiryan’s medical incompetency was a threat to patient safety, the Medical Staff summarily suspended her privileges pending an investigation, without providing prior notice or a hearing.

Geffner v. Board of Psychology (Feb. 28, 2024, B322991) __ Cal.App.5th __ [2024 WL 834986]

After two brothers (both minors) expressed suicidal and homicidal ideations, their mother asked Dr. Robert Geffner, a psychologist, to evaluate them. Both said they would act on these thoughts if they saw their father. Dr. Geffner recommended that the brothers be kept away from their father until further treatment and a risk assessment was completed. Dr. Geffner also said that the father needed to be warned of this threat, and he requested confirmation that the father had received this warning within 24 hours. 

Symons Emergency Specialties v. City of Riverside (Jan. 9, 2024, E078113) __ Cal.App.5th __ [2024 WL 470492], ordered published Feb. 7, 2024

The Emergency Medical Services System and Prehospital Emergency Medical Care Act (the Act) (Health & Saf. Code, § 1797 et seq.) “precludes cities from regulating the provisions of emergency medical services.” But it has a “grandfathering” provision that allows a city to maintain control of services it operated or contracted for as of June 1980. Under this provision, the city can maintain control of prehospital emergency medical services until it reaches an agreement with the county to provide them.

Gardena Hospital, L.P. v. Baass (Feb. 9, 2024, B316529) __ Cal.App.5th __ [2024 WL 510108]

Gardena Hospital offers acute and long-term care. Its care for Medi-Cal patients is reimbursed by the state. The reimbursement formula divides costs by “patient days,” so Gardena gets a larger per diem if it reports fewer patient days. Relying on the state Accounting and Reporting Manual for California Hospitals (Hospital Manual), Gardena excluded “bed holds”—days where patients’ beds in the subacute care section are left empty because those patients are expected to return after receiving acute care—from reported patient days.

Abney v. State Dept. of Health Care Services (Jan. 31, 2024) __ Cal.App.5th __ [2024 WL 356944]

The Social Security Administration began withholding money from Debra Abney’s monthly Social Security payment to satisfy an IRS debt. Consistent with advice from the California Department of Health Care, which administers Medi-Cal, San Francisco counted the wage garnishment amount as income “actually available to meet [her] needs” and on that basis found Abney to be ineligible to receive Medi-Cal benefits without sharing the cost. The trial court denied her petitions seeking administrative writ relief from the eligibility decision. Abney appealed.