Plaintiffs (the deceased and his wife/trustee) sued the defendants (healthcare providers) for tort damages and injunctive relief from unfair business practices. Defendants demurred. The Superior Court of California, Orange County, sustained the demurrers without leave to amend and entered judgment. The Court of Appeal, Fourth Appellate District, Division Three, reversed. Review was granted.
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Overview
Plaintiff deceased suffered from progressive lung disease. He was a Medicare beneficiary enrolled in defendant provider’s health maintenance organization. Defendants repeatedly denied him a referral to a specialist for a lung transplant or other care. Plaintiff left the health plan in order to get on the Medicare transplant list. Plaintiffs filed suit, alleging various tort claims, including negligence, willful misconduct, and fraud. Defendants alleged that each of the claims arose under the Medicare Act, 42 U.S.C.S. § 1395 et seq., and, pursuant to 42 U.S.C.S. § 405(g), was therefore subject to judicial review only in federal court, after exhaustion of administrative review procedures. The trial court sustained the demurrers, and the court of appeals reversed. Because plaintiffs might be able to prove their claims without regard to Medicare coverage determinations, because none of their causes of action sought payment or reimbursement of a Medicare claim or fell within the Medicare administrative review process, and because the harm they allegedly suffered was not remediable within that process, it followed that the court of appeal correctly reversed the trial court’s orders.
Outcome
The court of appeal’s judgment was affirmed.