Wilson v. Blue Cross of So. California

• Decision Date: 27 July 1990
• Citation: 222 Cal.App.3d 660,271 Cal.Rptr. 876
• Court: California Court of Appeals
• Parties: Howard E. WILSON, Sr., individually and as Administrator of Howard Wilson, Jr., and Margaret P. Wilson, Plaintiffs and Appellants, v. BLUE CROSS OF SOUTHERN CALIFORNIA, a California corporation, Blue Cross and Blue Shield of Alabama, an Alabama corporation, Professional Standards Review Organization, Area 23, d/b/a Western Medical Review, a California corporation, John Wasserman, M.D., Does 1-50, inclusive, Defendants and Respondents. Civ. B040597.

Page 876

271 Cal.Rptr. 876

222 Cal.App.3d 660

Howard E. WILSON, Sr., individually and as Administrator of Howard Wilson, Jr., and Margaret P. Wilson, Plaintiffs and Appellants, v.BLUE CROSS OF SOUTHERN CALIFORNIA, a California corporation, Blue Cross and Blue Shield of Alabama, an Alabama corporation, Professional Standards Review Organization, Area 23, d/b/a Western Medical Review, a California corporation, John Wasserman, M.D., Does 1-50, inclusive, Defendants and Respondents.

Civ. B040597.

Court of Appeal, Second District, Division 5, California.

July 27, 1990.

Certified for Partial Publication ^*.

Review Denied Oct. 11, 1990.

Weissburg and Aronson, Inc., Peter Aronson, James R. Kalyvas, Stephen M. Levine, Los Angeles, for plaintiffs and appellants.

Rosato & Samuels, Cary S. Samuels, Michael Schloss, Studio City, for defendant and respondent Blue Cross of Southern California.

Gronemeier, Barker & Huerta, Neil J. Barker, Pasadena, Gail Ivens, Los Angeles, for defendant and respondent Blue Cross and Blue Shield of Ala.

Schaffer & Lax, Steven A. Lax, Jeannette L. Viau, Los Angeles, for defendants and respondents Western Medical Review and John Wasserman, M.D.

TURNER, Associate Justice.

I.INTRODUCTION

On March 1, 1983, Howard Wilson, Jr.(the decedent) was admitted to College Hospital in Los Angeles while suffering from major depression, drug dependency, and anorexia.His treating physician determined that he needed three to four weeks of in-patient care at the hospital.On March 11, 1983, through its agents, the decedent's insurance company announced that it would not pay for any further hospital care.Because nobody could afford to pay for any further in-patient hospital care, the decedent was discharged from College Hospital.On March 31, 1983, the decedent committed suicide.Because a triable issue exists as to whether the conduct of the decedent's insurance company and certain related entities was a substantial factor in causing the decedent's death, we conclude that the trial court incorrectly granted the summary judgment motions.

II.RESOLUTION OF PRINCIPAL LEGAL ISSUE

This is an appeal from several judgments imposed following orders granting summary judgment motions brought by four defendants.The orders granting summary judgment were premised upon the application of the holding of Wickline v. State of California(1986)192 Cal.App.3d 1630, 239 Cal.Rptr. 810, a decision of this division.In Wickline, this court filed a published opinion in 1986, the Supreme Court granted review, and in 1987 the opinion was reprinted for tracking purposes at 192 Cal.App.3d 1630, 239 Cal.Rptr. 810.On July 30, 1987, our Supreme Court dismissed review and ordered the matter transferred to this court pursuant to rule 29.4(c),California Rules of Court.The Supreme Court ordered that the opinion be published in the official reports and the opinion remains published at 192 Cal.App.3d 1630, 239 Cal.Rptr. 810.In its transfer and publication order of July 30, 1987, the Supreme Court referred to rule 978(c) of the California Rules of Court which provides, "An order of the Supreme Court directing publication of an opinion in the Official Reports shall not be deemed an expression of opinion by the Supreme Court of the correctness of the result reached by the decision or of any of the law set forth in the opinion."

Unlike a normal opinion where procedural and factual matters are initially developed, this case lends itself to the resolution of the key legal issue at the outset--the extent to which Wickline extends beyond the context of Medi-Cal patients to an insured under an insurance policy issued in the private sector.Because Wickline should be limited to its facts and the legal issues properly decided in that case, it may not serve as a basis for the orders granting the summary judgment motions filed in this case.

A.The Wickline Decision

In Wickline, the plaintiff was a Medi-Cal patient who was hospitalized.Her physician sought Medi-Cal authorization for an additional eight-day period of hospitalization but a board-certified surgeon employed as a consultant by Medi-Cal authorized payment for only four additional days of hospitalization.As a result, her principal treating physician, with the concurrence of two other treating doctors, discharged plaintiff after four additional days of hospitalization.(Wickline v. State of California, supra, 192 Cal.App.3d at pp. 1636-1637, 239 Cal.Rptr. 810.)The plaintiff's principal treating physician did not utilize a reconsideration procedure within the Medi-Cal funding process to seek an additional extension of benefits for further hospitalization.All of the expert opinion testimony indicated that the discharge decision "was ... within the standards of practice of the medical community...."(Id. at pp. 1640, 1646, 239 Cal.Rptr. 810.)After her discharge, the plaintiff in Wickline experienced further medical problems which led to the loss of her leg.

The Wickline court analyzed various statutory and administrative rules which authorized the denial of Medi-Cal benefits under particular circumstances.Provisions of former Welfare and Institutions Code section 14000 required in part that Medi-Cal funding for acute care be available to the poor " 'whenever possible and feasible ..., to the extent practical, ... to secure health care in the same manner employed by the public in generally....' "(Id. at p. 1646, 239 Cal.Rptr. 810.)The former provisions of 22 California Administrative Code section 51110 stated that the determination of need for acute care " 'shall be made in accordance with the usual standards of medical practice in the community.' "(Id. at p. 1645, 239 Cal.Rptr. 810.)Finally, the decision to withhold funding was made in full compliance with the provisions of the California Administrative Code and the Welfare and Institutions Code which permitted a Medi-Cal consultant to review requests by a private health care provider for Medi-Cal funding for a patient and, in appropriate cases, to deny Medi-Cal benefits.(Id. at pp. 1646-1647, 239 Cal.Rptr. 810.)

B.The Three Key Elements of Wickline.

In essence, Wickline, is a case involving three key legal and factual components.First, as a matter of law, the discharge decision met the standard of care for physicians.This is of particular importance given the fact that the Medi-Cal standard for determining whether to provide acute care was essentially the same as the standard of care for physicians.

Second, the funding process was not pursuant to a contract; rather, the determination as to whether the state had a duty to provide funds was made pursuant to statute and provisions of the California Administrative Code.These statutes and regulations altered the normal course of tort liability set forth in Civil Code section 1714 which provides that " '[e]very one is responsible, not only for the result of his [or her] willful acts, but also for an injury occasioned by another by his [or her] want of ordinary care or skill....' "(Id. at p. 1643, 239 Cal.Rptr. 810.)Citing Rowland v. Christian(1968)69 Cal.2d 108, 112, 70 Cal.Rptr. 97, 443 P.2d 561, the Wickline court noted: "Rephrased, it establishes the general rule that ' "[a]ll persons are required to use ordinary care to prevent others being injured as a result of their conduct." 'And, ' "in the absence of statutory provision [sic] declaring an exception to the fundamental principle enunciated by section 1714 of the Civil Code, no such exception shall be made unless clearly supported by public policy." ' "(Wickline v. State of California, supra, 192 Cal.App.3d at p. 1643, 239 Cal.Rptr. 810.)The public policy identified by the Wickline court which constituted an exception to Civil Code section 1714 were the provisions of statutory and regulatory law which permitted the state to deny Medi-Cal benefits when to do so was " 'in accordance with the usual standards of medical practice in the community.' "(Id. at p. 1645, 239 Cal.Rptr. 810.)As noted previously, in Wickline, all of the physicians who testified stated that the discharge decision fell within the standard of practice.The Wickline court correctly concluded that the public policy as expressed in the Welfare and Institutions CodeandTitle 22 of the California Administrative Code constituted an exception to the usual standard of tort liability specified in Civil Code section 1714.As will be noted, no such statutory and regulatory scheme is present in the case at bar and the general rule of tort liability set forth in Civil Code section 1714 must apply to the parties in this case.

Third, Wickline was not a case where a cost limitation program such as the Medi-Cal review process was "permitted to corrupt medical judgment."(Wickline v. State of California, supra, 192 Cal.App.3d at p. 1647, 239 Cal.Rptr. 810.)The Wickline court emphasized that a patient "who requires treatment and who is harmed when care which should have been provided is not provided should recover for the injuries suffered from all those responsible for the deprivation of such care, including, when appropriate, health care payors."(Id. at p. 1645, 239 Cal.Rptr. 810.)As will be noted, none of these three factors were directly applicable to any of the summary judgment motions in the present case.Therefore, the holding of Wickline does not extend to this present case.

C.The Wickline Dicta

Before proceeding to evaluate the three summary judgment motions in this case, an additional comment is in order concerning Wickline.The moving parties in the trial court in their papers focused on language in Wickline which must frankly be categorized as dicta.For example, the opinion states: "However, the physician who complies without protest with the limitations imposed by a third party payor, when [her or] his medical judgment dictates otherwise, cannot avoid his [or her] ultimate responsibility for [her or] his patient's care.He[or ...