Allied Anesthesia Medical Group v. Inland Empire Health Plan
Annotate this CaseDefendant-respondent Inland Empire Health Plan (IEHP) was a health care service plan subject to the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act). It contracted with certain medical groups and providers to provide medical care at reduced costs to eligible beneficiaries of the California Medical Assistance Program (Medi-Cal or Medicaid) who were enrolled with IEHP. Plaintiffs-appellants Allied Anesthesia Medical Group, Inc., and Upland Anesthesia Medical Group were groups of doctors who provided anesthesia services to IEHP’s enrollees for elective, nonemergency surgeries. Plaintiffs had no provider contract with IEHP; however, they had exclusive agreements with the hospitals. Plaintiffs were paid at the Medi-Cal fee schedule rate. In this case, plaintiffs claimed IEHP should have paid them at the reasonable and customary value rate for their services instead of the Medi-Cal fee schedule rate, and requested a declaratory judgment based solely upon the Knox-Keene Act and the Claims Settlement Practices regulation. IHEP demurred on several grounds, including: (1) the cause of action for breach of implied-in-fact contract fails to sufficiently plead “mutual assent” and “legal consideration”; and (2) the cause of action for breach of contract (third party beneficiary) failed to allege how plaintiffs were the express, intended third party beneficiaries of any contract between IEHP and the California Department of Health Care Services. The trial court agreed with IEHP, sustained its demurrer without leave to amend, and entered judgment. Plaintiffs appealed, maintaining IEHP was obligated to pay them the reasonable and customary value rate for their services to IEHP’s enrollees. To this the Court of Appeal disagreed and affirmed the trial court.
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