Aton Ctr., Inc. V. Blue Cross & Blue Shield. (U.S. Dist. CT. for the Southern District of California on February 1, 2021, case no. 3:20-cv-00492-WQH-BGS). In this case, the Plaintiff, an inpatient residential substance abuse treatment facility, took steps to verify out-of-network coverage for several patients. The verification of benefits (VOB) process was important to Plaintiff to ensure rendered care would be paid for. Prior authorization was completed as well, and patients were told that reimbursement for claims would be based on 60% of the UCR. Defendant reimbursed at a lower rate, and Plaintiff filed nine legal actions in state court. After removing the case to federal court, Defendant health plan filed motion to dismiss.
Judge William Hayes made the following rulings on the nine causes of actions regarding Defendant’s motions to dismiss:
The Court noted that VOB and authorization calls alone are generally insufficient to form the basis for an oral or implied contract because they lack a manifestation of intent to enter into a contract. But the Court found that the amended complaint did allege sufficient facts to infer mutual consent in which “the parties all agreed upon the same thing in the same sense.” Therefore, Judge Hayes concluded that Plaintiff alleges a plausible claim for breach of oral contract against Defendant. Regarding the promissory estoppel claim, the Court found that the Plaintiff pleaded sufficient facts to infer a clear and unambiguous promise, and reasonable and foreseeable reliance on that promise. The other claims were dismissed due to the failure to plead sufficient facts or by operation of law (e.g., failure to state a claim where relief can be granted).