Other Insurance Claims

• Author: Kevin R. Culhane
• Pages: 119-139

19-119

Chapter 19

Other Insurance Claims

§1900 Managed Health Care Insurance Accountability Act of 1999

§1910 Deposition Checklists

§1900 Managed Health Care Insurance Accountability Act of 1999

§1901 Basic Information Regarding Parties

§1902 Plan Enrollment

§1903 Persons Entitled to Health Care Benefits

§1904 Treatment Recommendation by Health Care Provider

§1905 Experts Used in Evaluation Process

§1906 Denial of Health Care Service

§1907 Delay of Recommended Health Care Services

§1908 Modification of Recommended Health Care Service

§1909 Plan Decisions Resulting in Substantial Harm

§1910 Deposition Checklists

§1911 Deposition of Defendant

§1911.1 Defendant – General Background

§1911.2 Plan Enrollment

§1911.3 Treatment Recommendation by Healthcare Provider

§1911.4 Plan Evaluation of Healthcare Provider Recommendation

§1911.5 Conduct Alleged to Violate the Managed Healthcare Insurance Accountability Act

§1911.6 Causation: Plan Decision Resulting in Substantial Harm

§1911.7 Damages

§1911.8 Affirmative Defenses and Denials

§1911.9 Statements by Parties, Witnesses

§1911.10 Surveillance Conducted by Defendant

§1911.11 Insurance

§1912 Deposition of Plaintiff

§1912.1 Plaintiff – General Background

§1912.2 Plan Enrollment

§1912.3 Treatment Recommendation by Healthcare Provider

§1912.4 Plan Evaluation of Healthcare Provider Recommendation

§1912.5 Conduct Alleged to Violate the Managed Healthcare Insurance Accountability Act

§1912.6 Causation: Plan Decision Resulting in Substantial Harm

§1912.7 Damages

§1912.8 Affirmative Defenses And Denials

§1912.9 Statements by Parties, Witnesses

§1912.10 Surveillance Conducted by Opposing Party

§1900 Model InterrogatorIes 19-120

§1900 Managed Health Care Insurance Accountability Act of 1999

In an innovative response to concerns regarding health treatment decisions dictated by administrators of health

care service plans and managed care entities that interfere with the recommendations of health care providers, the

California Legislature enacted the Managed Health Care Insurance Accountability Act of 1999 (hereinafter the

“Act”). In general, the legislation imposes upon health care service plans and managed care entities a duty of ordinary

care to arrange for the provision of medically necessary health care services to enrollees, and further imposes liability

on these entities for harm occasioned by their failure to do so. The liability is imposed when 1) the failure to exercise

ordinary care results in the denial, delay or modification of the health care service recommended by a health care

provider; and 2) the enrollee suffers substantial harm. (cal. cIV. code §3428(a).)

The legislative findings adopted in connection with the Act reveal a determination by the Legislature that health

care service plans and other managed care entities are in fact engaged in the business of insurance. (See SB-21

(Figueroa and Kuehl, Chapter 536 §2(a)(1).) The prohibited conduct is therefore similar to the liability imposed

upon insurance carriers, i.e., liability is imposed when the provider improperly denies, delays or modifies the health

care recommended by the medical professional. (See, e.g., §740 et seq. pertaining to an insurance carrier’s denial of

policy benefits.) The legislative finding that managed care entities in fact engage in the business of insurance has an

additional purpose; the finding is intended to insulate the statute from a claim that it is preempted by the Employee

Retirement Income Security Act of 1974 (ERISA) 29 U.S.C. §1144(a) by invoking the federal prohibitions upon the

national regulation of insurance matters under the McCarran-Ferguson Act (15 U.S.C. §1011 et seq.).

The sections that follow contain interrogatories for use in claims brought under the Act, and also set forth appro-

priate cross-references to other sections of this book containing interrogatories that may be useful in litigating claims

under the Act.

§1901 Basic Information Regarding Parties

Liability under the Act is imposed in favor of “subscribers and enrollees” against “health care service plans or

managed care entities.” Accordingly, the interrogatories set forth in §210 (Identification of Parties) may be used to

obtain the basic background information regarding the identity of plaintiff; the interrogatories set forth at §720 (Basic

Insurer Information) may be easily adapted to provide identification, business format and qualification data regarding

the defendant.

§1902 Plan Enrollment

As noted above, the liability imposed under the Act runs in favor of “subscribers and enrollees” of health care

service plans and managed care programs. The interrogatories set forth in this section seek basic data regarding the

plaintiff’s enrollment in the plan. The responses to these interrogatories will serve to identify the plan documents so

that you may propound a request for production. The responses will also identify applicable plan limitations, policy

limits and effective dates.

1. Please state whether, during the time frame from ________ to ________, inclusive [plaintiff] [subscribed/

enrolled] to a [health care service plan/managed care program] administered by YOU.

2. If your answer to interrogatory no. 1 was yes, please set forth the [subscriber/enrollee] number assigned to

the plaintiff.

3. If your answer to interrogatory no. 1 was yes, please identify each [plan document/benefit summary] applica-

ble to such plan.

4. As to each document identified in your answer to interrogatory no. 3, please IDENTIFY the pres ent

CUSTODIAN of each such document.