Tenet Healthsystem Desert v. Blue Cross of Cal.
Annotate this CasePlaintiff Tenet Healthsystem Desert, Inc. (Hospital) appealed a judgment entered in favor of defendants Blue Cross of California, doing business as Anthem Blue Cross (Blue Cross), Anthem Blue Cross Life and Health Insurance Company (BC Life), and Anthem UM Services, Inc. (Anthem UM). Hospital sued Anthem, as well as Eisenhower Medical Center (Eisenhower) and Keenan & Associates (Keenan), when the defendants refused to pay approximately $1.9 million the cost of medical services that Hospital provided to an insured patient following extensive communications with Anthem over a period of approximately 50 days regarding "authorization" for the services. The defendants ultimately denied coverage for the medical services based on an exclusion in the patient's policy for injuries sustained as a result of having a blood alcohol level over the legal limit. Hospital alleged that Anthem's continuing to "authorize" medical services during the patient's stay at Hospital, even after Anthem was made aware that the patient was admitted with a blood alcohol level far exceeding the legal limit, constituted a misrepresentation as to coverage, on which Hospital relied in providing care to the patient. The trial court determined that the Hospital's third amended complaint (TAC) lacked the necessary specificity to survive a demurrer, and entered judgment for Anthem. The Court of Appeal, however, reversed, concluding the TAC alleged facts with sufficient particularity to overcome a demurrer. The Court therefore reversed and remanded the matter to the trial court for further proceedings.
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