Statement Settlement ConferenceCal. Super. - 6th Dist.October 19, 2018GOOQQUl-RUJNr-ik NNNNNNNNNr-dr-dr-dr-Ar-Ar-Ar-AHHH OOQQU‘I-hUJNF-‘OKOOOQQU‘I-RUJNHO 180V336774 Santa Clara - Civil LAW OFFICES OF STEPHENSON, ACQUISTO & MMMaINCEiIed JOY STEPHENSON-LAWS, ESQ. (SBN llmwperior Court 0f CA, Q9 ty of Santa Clara,RICHARD A. LOVICH, ESQ. (SBN 113 é [5/2021 427 PMCHRISTOPHER HAPAKaESQ. (SBN 26721 pewed By: System Syste. 303 N. Glenoaks B1Vd., Sulte 700 Case #1 3cv336774 Burbank, California 91502 Envelope: 7405185 Telephone: (818) 559-4477 Facsimile: (818) 559-5484 Attorneys for Plaintiff CALIFORNIA SPINE AND NEUROSURGERY INSTITUTE, a California for profit corporation SUPERIOR COURT OF CALIFORNIA FOR THE COUNTY OF SANTA CLARA UNLIMITED JURISDICTION CALIFORNIA SPINE AND Case N0.: 18CV336774 NEUROSURGERY INSTITUTE, a 9 California for profit corporation PLAINTIFF S SETTLEMENT CONFERENCE STATEMENT Plaintiff, MSC Date: October 13, 2021 V Trial Date: October 18, 2021AETNA, INC., a Pennsylvania Corporation, AETNA LIFE INSURANCE COMPANY, a Connecticut Corporation, and SAP AMERICA, INC., a Delaware Corporation; and DOES 1 THROUGH 25, inclusive, Defendants. System System TI 22862 _ 1 _ PLAINTIFF’S SETTLEMENT CONFERENCE STATEMENT GOOQQUl-RUJNr-ik NNNNNNNNNr-dr-dr-dr-Ar-Ar-Ar-AHHH OOQQU‘I-hUJNF-‘OKOOOQQU‘I-RUJNHO California Spine and Neurosurgery Institute (“California Spine”) hereby respectfillly submits its mediation brief in its case against AETNA, INC, a Pennsylvania Corporation, AETNA LIFE INSURANCE COMPANY, a Connecticut Corporation, and SAP AMERICA, INC. (collectively “Defendants” 0r “Aetna”) I. INTRODUCTION AND SUMMARY OF ARGUMENT This case involves a dispute between California Spine and Aetna for the medical care California Spine rendered t0 Patient R.C. and Patient J.P., “Patients”), who were beneficiaries of Aetna’s plan through SAP, Inc. Aetna contends that it is not responsible for additional payment related to the medically necessary services the Patients received from California Spine from March 5 to August 6 in 2018. Aetna contends there was no implied-in-fact or express contract in existence t0 establish reasonable and customary charges were due t0 California Spine. California Spine’s position is simple: Aetna expressly represented to California Spine that no authorization was required for Patients to receive services for minimally invasive spine surgery by California Spine. Aetna also provided verification 0f benefits and eligibility for out-of-network services prior to the Patients receiving medically necessary services from California Spine. California Spine fully relied 0n the representations and the assurances made by Aetna t0 provide medically necessary treatment t0 the Patients. Partial payments have been made on the claims for the Patients. As such, the true dispute here is not whether payment is owed by Aetna, but the appropriate rate ofpayment t0 be paid on the claims. Aetna should be required to compensate California Spine for the full amount of damages- i.e. $154,503.05. III. FACTUAL BACKGROUND Patient R.C. On or about April 20, 2017, California Spine was informed by Aetna client services representative, known as "Kim," 0f Patient R.C.'s benefits regarding outpatient procedures such as spine surgery and using a provider Who is non-contracted with Aetna and SAP America. By 22862 _ 2 _ PLAINTIFF’S SETTLEMENT CONFERENCE STATEMENT GOOQQUl-RUJNr-ik NNNNNNNNNr-dr-dr-dr-Ar-Ar-Ar-AHHH OOQQU‘I-hUJNF-‘OKOOOQQU‘I-RUJNHO its agent, Aetna represented that reimbursement would be "80% of the usual and customary rate." Also, on or about April 20, 2017, Aetna's client services representative represented to California Spine that under the terms 0f Patient R.C.'s health plan, n0 pre-authorization was required for an outpatient procedure such as the surgery received by Patient R.C. On August 8, 2017, based upon existence 0f an identification card issued by Aetna and SAP America, the telephone call With Aetna, and the express and/or implied resultant assurances that California Spine would be paid at least 80% the usual and customary value 0f its medical services anticipated to be rendered t0 Patient R.C., California Spine provided medically necessary and minimally invasive spine surgery upon Patient R.C. As directed by Patient R.C.'s Aetna/SAP America identification card, California Spine timely and properly submitted a bill t0 Aetna for medically necessary services, supplies, and/or equipment it rendered t0 Patient R.C. in the amount of $87,500 Which represents California Spine's usual and customary charges for such services (and such care's usual and customary value). By doing so, California Spine expected Defendants t0 pay at least 80% of the usual and customary value for such care, 0r $70,000. Defendants paid only $4,697.35 of the $87,500 bill for the medically necessary procedures and treatment rendered to Patient R.C. by California Spine. After deduction 0f that payment, Aetna and/or SAP America failed t0 pay the remaining $65,302.65 for the medical care rendered t0 Patient R.C. In addition, Aetna allocated only 6,063.15 as patient responsibility, thus directing California Spine t0 pursue any disputes directly With Defendants named herein. Patient J.P.- On or about April 26, 2017, California Spine was informed by Aetna client services representative, known as "Leo B.," 0f Patient J.P.'s benefits regarding outpatient procedures such as spine surgery and using a provider Who is non-contracted with Aetna/SAP America. By its agent, Aetna represented that reimbursement would be "based on 80%" 0f the usual and customary rate. Also, 0n 0r about April 26, 2017, Aetna's client services representative represented t0 California Spine that under the terms 0f Patient J.P.'s health plan, n0 pre- authorization was required for an outpatient procedure such as the surgery received by Patient J.P. On May 25, 2017, based upon existence 0f an identification card issued by Aetna and SAP America, the telephone call with Aetna, and the express and/or implied resultant assurances that California Spine would be paid at least 80% 0f the usual and customary value 0f its medical 22862 _ 3 _ PLAINTIFF’S SETTLEMENT CONFERENCE STATEMENT GOOQQUl-RUJNr-ik NNNNNNNNNr-dr-dr-dr-Ar-Ar-Ar-AHHH OOQQU‘I-hUJNF-‘OKOOOQQU‘I-RUJNHO services anticipated to be rendered t0 Patient J.P., California Spine provided medically necessary and minimally invasive spine surgery upon Patient J.P. As directed by Patient J.P.'s Aetna/SAP America identification card, California Spine timely and properly submitted a bill to Aetna for medically necessary services, supplies, and/or equipment it rendered to Patient J.P. in the amount of $ 12 1 ,000 Which represents California Spine's usual and customary charges for such services (and such care's usual and customary value). By doing so, California Spine expected Defendants t0 pay at least 80% 0f the usual and customary value for such care, 0r $96,800. Defendants paid only $7,599.60 0f the $121,000 bill for the medically necessary procedures and treatment rendered t0 Patient J.P. by California Spine. After deduction of that payment, Aetna and/or SAP America failed t0 pay the remaining $89,200.40 for the medical care rendered to Patient J.P. Aetna allocated only $4,580.00 as patient responsibility, thus directing California Spine t0 pursue any disputes directly With Defendants named herein. IV. ARGUMENT The implied-in-fact and express contractl causes of action in the civil complaint are based upon the representations made by Aetna t0 California Spine. So as to maintain a cause 0f action for breach 0f contract, a plaintiff must establish the following: (1) the existence 0f a contract and its terms; (2) plaintiffs performance 0r excuse for nonperformance; (3) breach by defendant; and (4) that the breach caused plaintiffs harm. Here, there exists a contract between California Spine and Aetna such that Aetna is financially responsible t0 pay 80% 0f the usual and customary value 0f services rendered by California Spine to the Patients; California Spine performed its duty under contract by rendering services to the Patients; Aetna breached by paying an amount less than the agreed upon 80% of usual and customary value of services; and (4) Aetna’s breach has caused California Spine to be harmed in the amount set forth as damages 1Express and implied-in-fact contracts have the same legal effect, but differ in how they are proved at trial: “ “Contracts may be express 0r implied. These terms, however, do not denote different kinds of contracts, but have reference t0 the evidence by Which the agreement between the parties is shown. If the agreement is shown by the direct words of the parties, spoken or written, the contract is said to be an express one. But if such agreement can only be shown by the acts and conduct of the parties, interpreted in the light of the subject-matter and 0f the surrounding circumstances, then the contract is an implied one.’ ” Marvin V. Marvin (1976) 18 Cal.3d 660, 678, fn. 16 [134 Cal.Rptr. 815,557 P.2d 106], internal citation omitted. 22862 _ 4 _ PLAINTIFF’S SETTLEMENT CONFERENCE STATEMENT GOOQQUl-RUJNr-ik NNNNNNNNNr-dr-dr-dr-Ar-Ar-Ar-AHHH OOQQU‘I-hUJNF-‘OKOOOQQU‘I-RUJNHO in the First Amended Complaint. V. CONCLUSION While California Spine is confident that it would recover in full should the matter proceeded to trial, California Spine Will appear at the mediation and make a good faith effort t0 resolve this dispute. Dated: 5 October 2021 LAW OFFICES OF STEPHENSON, ACQUISTO & COLMAN, INC. fifiw? CHRISTOPHER HAPAK Attorneys for Plaintiff CALIFORNIA SPINE AND NEUROSURGERY INSTITUTE 22862 _ 5 _ PLAINTIFF’S SETTLEMENT CONFERENCE STATEMENT GOOQQUl-RUJNr-ik NNNNNNNNNr-dr-dr-dr-Ar-Ar-Ar-AHHH OOQQU‘I-hUJNF-‘OKOOOQQU‘I-RUJNHO PROOF OF SERVICE I am employed in the county of Los Angeles, State 0f California. I am over the age 0f 18 and not a party to the within action; my business address is 303 North Glenoaks Boulevard, Suite 700, Burbank, California 91502-3226. On 5 October 2021, I served the foregoing document(s) entitled: PLAINTIFF’S SETTLEMENT CONFERENCE STATEMENT By placing a true copy thereof enclosed in a sealed envelope addressed per the attached Service List. [] BY U.S. MAIL: I am "readily familiar" with the firm's practice of collection and processing correspondence for mailing. Under that practice it would be deposited With the United States Postal Service on that same day with postage thereon fully prepaid at Burbank, California in the ordinary course 0f business. I am aware that on motion 0f the party served, service is presumed invalid if postal cancellation date or postage meter date is more than one day after date 0f deposit for mailing in affidavit. [C.C.P. 1013a(3); F.R.C.P. 5(b)] BY FEDERAL EXPRESS: I caused such envelope(s), with overnight Federal Express Delivery Charges t0 be paid by this firm, t0 be deposited with the Federal Express Corporation at a regularly maintained facility 0n the aforementioned date. [C.C.P. 1013(0) 1013(d)] BY PERSONAL SERVICE: I caused the above-stated document(s) t0 be served by personally delivering a true copy thereof t0 the individuals identified above. [C.C.P. 101 1(a); F.R.C.P. 5(b)] BY EXPRESS MAIL: I caused such envelope(s), With postage thereon fully prepaid and addressed to the party(s) shown above, t0 be deposited in a facility operated by the U.S. Postal Service and regularly maintained for the receipt of Express Mail 0n the aforementioned date. [C.C.P. 1013(0)] BY TELECOPIER: Service was effected on all parties at approximately__ am/pm by transmitting said document(s) from this firm's facsimile machine (818/559-4477) t0 the facsimile machine number(s) shown above. Transmission t0 said numbers was successful as evidenced by a Transmission Report produced by the machine indicating the documents had been transmitted completely and without error. C.R.C. 2008(6), Cal. CiV. Proc. Code § 1013(6). 22862 _ 6 _ PLAINTIFF’S SETTLEMENT CONFERENCE STATEMENT GOOQQUI-RUJNH NNNNNNNNNr-tr-tr-tr-tr-Ar-Hr-tr-tr-k OOQQUI-bUJNP-‘OKOOOQQUIAUJNF-‘O [X ] BY ELECTRONIC SERVICE: By emailing true and correct copies t0 the persons at the electronic notification address(es) shown 0n the accompanying service list. The document(s) was/were served electronically and the transmission was reported as complete and Without error. [ X ] State: I declare under penalty of perjury under the laws of the State of California that the above is true and correct. Executed 0n 5 October 2021 in Burbank, California. WWW ANGELA DEMERS SERVICE LIST Curtis S. Leavitt, Esq. Paula Hendrickson Alexander Nowinski, Esq. phendrickson@kennadavleavitt.com KENNADAY LEAVITT OWENSBY PC 621 Capitol Mall, Suite 2500 Tawinder K. Sandhu Sacramento, CA 95814 tsandhu@kennadavleavitt.com (9 1 6) 732-3060 cleavitt@kennadavleavitt.com anowinski@kennadavleavitt.com 22862 _ 7 _ PLAINTIFF’S SETTLEMENT CONFERENCESTATEMENT