The Beverly Hills Regional Center, L.P. (BHRC) sued insurance company Premera Blue Cross on Monday in Los Angeles County Superior Court. The complaint for negligent misrepresentation and breach of written contract comes after the defendant made numerous payments to the plaintiff that were well under the previously agreed-upon usual and customary rate.
After the medical provider determined that a patient, J.S., would need surgery, they contacted the defendant to discuss how the services would be paid for. The defendant represented to them that once the patient met the Max Out Of Pocket (MOOP) expense of $6,600, the defendant would be responsible for the rest of the balance and that the payment would not be based on the Medicare Fee Schedule. The plaintiff maintains that they were never informed of the insurance being “subject to certain exclusions, limitations or qualifications, which might result in the denial of coverage, limitation of payment or any other method of payment unrelated to the UCR rate.”
The complaint details that the defendant knew or should have known that they would be paying the plaintiff at the Medicare rate rather than the UCR rate, yet they never communicated that to the plaintiff. Following the procedure, BHRC billed the defendant $238,289.00. After processing the bill, the defendant made a payment of $10,609.40. They have since refused to make an appropriate payment fulfilling the remainder of the bill.
The defendant exhibited the same behavior in the instances of multiple other patients. Despite having contractual obligations to pay the plaintiff in accordance with the Patients’ plan documents and agreements, the defendant continually failed to make the full payments to BHRC.
The complaint cites the defendants’ negligent misrepresentation and breach of written contract. The misconduct on behalf of Premera Blue Cross has led the plaintiff to seek a trial by jury, compensatory damages, restitution, a declaration that the defendant is obligated to pay them all monies owed for services rendered to patients, and any other relief deemed appropriate by the Court.
The plaintiff is representing themselves in the litigation, while the defendant is represented by Karr Tuttle Campbell.
