Quattrocchi v. Allstate Indemnity Company

Filing 22

ORDER signed by District Judge John A. Mendez on 1/8/18. The Court GRANTS 12 Motion to Dismiss with prejudice. CASE CLOSED. (Mena-Sanchez, L)

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1 2 3 4 5 6 UNITED STATES DISTRICT COURT 7 EASTERN DISTRICT OF CALIFORNIA 8 9 DEBORAH QUATTROCCHI, 10 2:17-cv-01578-JAM-EFB Plaintiff, 11 12 No. v. ALLSTATE INDEMNITY COMPANY, 13 ORDER GRANTING ALLSTATE INDEMNITY COMPANY’S MOTION TO DISMISS Defendant. 14 Plaintiff Deborah Quattrocchi (“Plaintiff” or “Quattrocchi”) 15 16 suffered injuries from an auto accident in 2014. 17 Compl. (“FAC”) ¶ 2, Notice of Removal, ECF No. 1-1, Ex. A. 18 her primary medical plan paid for her medical bills, Plaintiff 19 reimbursed the primary medical plan from proceeds she obtained 20 from a settlement with a third-party tortfeasor. 21 Plaintiff then sought excess coverage from Defendant Allstate 22 Indemnity Company (“Defendant” or “Allstate”) to cover up to 23 $5,000 of these medical bills under the party’s policy agreement 24 (the “Policy”). 1 Id. ¶¶ 18-19, 22. First Am. After Id. ¶ 3. After Defendant declined 25 1 26 27 As Defendant points out in its reply brief, Plaintiff appears to seek a double recovery — her medical bills have been paid for by Kaiser, and she reimbursed Kaiser using the proceeds from her settlement with the tortfeasor. Reply at 2, ECF No. 20. 28 1 1 coverage, Plaintiff sued it for violating California’s Unfair 2 Competition Law, codified at Cal. Bus. & Prof. Code § 17200 et 3 seq. (“UCL”). 4 for failure to state a claim. 2 5 opposes. 6 Court grants Defendant’s motion with prejudice. See generally FAC. Defendant now moves to dismiss See Mem., ECF No. 12. See Opp’n, ECF No. 17. Plaintiff For the reasons below, the 7 8 I. 9 FACTUAL AND PROCEDURAL BACKGROUND In July 2014, Plaintiff suffered injuries from an auto 10 accident. 11 her primary medical plan, Kaiser. 12 reimbursed Kaiser for the amount of that coverage with the 13 proceeds from a settlement she reached with the driver of the 14 other vehicle from her auto accident. 15 2015, Plaintiff made a demand on Defendant for payment of up to 16 $5,000 for her bodily injury medical treatment under the excess 17 coverage provisions of the Policy. 18 FAC ¶¶ 2, 13. Her medical bills were covered through Id. ¶¶ 3, 17. Id. ¶ 18. Plaintiff later In December Id. ¶¶ 19, 22. Defendant denied payment one week later and requested proof 19 of Plaintiff’s claim, following the terms of the Policy. 3 20 ¶ 19. 21 “any person making claim must give us written proof of claim. 22 2 23 24 25 26 27 28 FAC Specifically, the Policy states, in relevant part, that It This motion was determined to be suitable for decision without oral argument. E.D. Cal. L.R. 230(g). The hearing was scheduled for December 5, 2017. In deciding this motion, the Court takes as true all well-pleaded facts in the operative complaint. 3 Defendant requested the Court take judicial notice of the Policy since it is central to the complaint. Defendant’s Request For Judicial Notice, ECF No. 12-1. The Court grants Defendant’s request. See Lee v. City of Los Angeles, 250 F.3d 668, 688 (9th Cir. 2001), overruled on other grounds by Galbraith v. County of Santa Clara, 307 F.3d 1119, 1125-26 (9th Cir. 2002). 2 1 must include all details we may need to determine the amounts 2 payable.” 3 Notice, ECF No. 12-1, (emphasis bolded in original). 4 response, Plaintiff submitted what she believed to be the 5 requested additional information. 6 Policy, AU104-3 at 12, Ex. A. to Request for Judicial In FAC ¶ 20. In May 2016, Defendant responded and again declined payment, 7 claiming that “Allstate covers only those charges for which you 8 must pay out-of-pocket such as co-pays and deductibles after your 9 primary health plan has processed their portion of the claim.” 10 FAC ¶ 21. 11 will not be liable to the extent that any elements of loss 12 covered under Coordinated Medical protection are paid, payable or 13 required to be provided to or on behalf of you or a resident 14 relative under the provisions of any and all primary medical 15 plans” and that “Coverage CX will apply on a primary basis to 16 expenses for elements of loss which are not covered under the 17 primary medical plan applicable to you or resident relatives.” 18 Policy at 4 (emphasis bolded in original). 19 The Policy states, in relevant part, that “Allstate After Defendant denied Plaintiff coverage under the Policy, 20 she brought this suit on December 16, 2016 in Sacramento County 21 Superior Court, claiming Defendant violated the UCL by denying 22 her coverage. 23 subsequently amended the complaint. 24 Defendant then removed the lawsuit to this Court on July 31, 25 2017. 26 /// 27 /// 28 /// See Compl., Ex. A to Notice of Removal. Notice of Removal. 3 Plaintiff See generally FAC. 1 2 II. OPINION Defendant argues Plaintiff’s UCL claim fails because the 3 Policy permitted Defendant to require documentation of 4 Plaintiff’s claims and to decline to pay Plaintiff’s claims where 5 a primary medical plan paid for Plaintiff’s treatment, even 6 though she later reimbursed the primary medical plan out of the 7 proceeds from a settlement. 8 9 See Mem. at 8-9. The Court agrees. To bring a UCL claim under Cal. Bus. & Prof. Code § 17200 et seq., a plaintiff must show either (1) unlawful, unfair, or 10 fraudulent business acts or practices, or (2) unfair, deceptive, 11 untrue, or misleading advertising. 12 Servs., Inc., 340 F.3d 1033 (9th Cir. 2003). 13 survive a motion to dismiss, a plaintiff must establish that the 14 practice is either (1) proscribed by law, (2) unfair, meaning the 15 harm to the victim outweighs any benefit, or (3) fraudulent, 16 meaning it is likely to deceive members of the public. 17 Lippitt v. Raymond James Fin. If the claim is to See id. Courts have dismissed UCL claims where the defendant has 18 followed the express language of unambiguous provisions from 19 insurance policies and other contracts. 20 Corp., No. 4:09-CV-01801SBA, 2009 WL 3152055 (N.D. Cal. Sept. 23, 21 2009) (finding no contractual violation where insurer denied 22 benefits for home health care services provided by plaintiff’s 23 children because the policy did not cover services provided by 24 family members); see also Baymiller v. Guarantee Mut. Life Co., 25 No. SA CV 99-1566 DOC AN, 2000 WL 1026565, at *4 (C.D. Cal. May 26 3, 2000) (dismissing UCL claim where the alleged misconduct of 27 misrepresenting how insurance charges would be calculated and 28 whether premiums would vanish was consistent with the express 4 See Guerard v. CAN Fin. 1 language of the applicable insurance policies); Roots Ready Made 2 Garments Co., W.L.L. v. Gap, Inc., 405 F. App’x 120, 122-23 (9th 3 Cir. 2010) (affirming dismissal of UCL claim because Gap’s 4 termination of the contract before plaintiff could recoup its 5 investment was permitted by the contract and courts lack the 6 license to review the fairness of contracts). 7 the plain language of an insurance policy is ‘clear and 8 unambiguous, the court must enforce it as written and cannot 9 modify the contract or create ambiguity where none exists.’ ” Indeed, “[w]here 10 Oceanside Pier View, L.P. v. Travelers Prop. Cas. Co. of America, 11 No. 07CV1174 WQH POR, 2008 WL 7822214, at *6 (S.D. Cal. May 6, 12 2008) (quoting Contractors Equip. Maint. Co. v. Bechtel Hanford, 13 Inc., 514 F.3d 899, 903 (9th Cir. 2008)). 14 Plaintiff alleges Defendant violated the UCL by(1)improperly 15 requiring Plaintiff to submit her health insurer’s explanation of 16 benefits showing its payment consideration of the relevant bills 17 when the Policy does not contain such a requirement and 18 (2) declining to pay Plaintiff’s claims where a primary medical 19 plan paid for the relevant medical treatment and then Plaintiff 20 reimbursed the primary medical plan for the cost of this care 21 from the proceeds of a settlement. FAC ¶¶ 3-6, 42. 22 A. Defendant’s Proof Of Loss Requirement 23 The Court finds that Plaintiff’s first allegation of a UCL 24 violation fails because Defendant enforced the express conditions 25 of the Policy in requiring Plaintiff to provide a proof of claim. 26 Insurers may deny coverage based on a plaintiff’s failure to 27 provide a proof of claim. See, e.g., 1231 Euclid Homeowners 28 Ass’n v. State Farm Fire & Cas. Co., 135 Cal. App. 4th 1009, 1018 5 1 (2005) (“total failure to comply with the notice and proof of 2 loss conditions will excuse insurer liability due to the failure 3 of a condition precedent. . . . The burden is on the insured to 4 initiate and support a claim.”) (citations omitted); Abdelhamid 5 v. Fire Ins. Exch., 182 Cal. App. 4th 990, 1000 (2010) (“The 6 deficiencies in Abdelhamid’s proof of loss were a far cry from 7 minor defects and no reasonable trier of fact could conclude she 8 substantially performed her obligations or complied with the 9 condition of her insurance contract requiring her to provide a 10 11 proof of loss with supporting documentation.”) Here, the Policy provides that “any person making claim must 12 give us written proof of claim. It must include all details we 13 may need to determine the amounts payable.” 14 (emphasis bolded in original). 15 provided that Defendant required Plaintiff to submit a proof of 16 claim, including showing her health insurer’s actions in 17 connection with the subject medical bill. 18 requirement was an unambiguous part of the Policy, Defendant 19 cannot be liable for violating the UCL by following the Policy. 20 See Guerard, 2009 WL 3152055; see also Baymiller, 2000 WL 21 1026565, at *4; Roots Ready Made Garments Co., 405 F. App’x at 22 122-23. 23 B. 24 The Court also finds that Plaintiff’s second allegation of a Policy at 12 So Plaintiff’s Policy expressly Because this Defendant’s Refusal To Pay Benefits 25 UCL violation fails because the Policy allowed Defendant to deny 26 coverage where a primary medical plan paid for medical treatment. 27 28 Again, courts have found that no UCL claims lie where the defendant has followed the express language of unambiguous 6 1 provisions from insurance policies and other contracts. 2 Guerard, 2009 WL 3152055; see also Baymiller, 2000 WL 1026565, at 3 *4; Roots Ready Made Garments Co., 405 F. App’x at 122-23. See 4 The Policy in this case provides in relevant part that 5 “Allstate will not be liable to the extent that any elements of 6 loss covered under Coordinated Medical protection are paid, 7 payable or required to be provided to or on behalf of you or a 8 resident relative under the provisions of any and all primary 9 medical plans” and that “Coverage CX will apply on a primary 10 basis to expenses for elements of loss which are not covered 11 under the primary medical plan applicable to you or resident 12 relatives.” 13 the relevant medical bills were paid for by Kaiser, meaning the 14 Policy allowed Defendant to refuse coverage on those medical 15 bills. 16 Kaiser from the proceeds she obtained from a settlement does not 17 change the fact that the bills were first paid for and covered by 18 a primary medical plan (Kaiser). 19 Policy at 4 (emphasis bolded in original). Id.; see FAC ¶ 19. Here, That Plaintiff later reimbursed Because there is no language in the Policy that creates 20 ambiguity about coverage in this situation, Defendant followed 21 the explicit language of the Policy. 22 for finding that Defendant violated the UCL by denying coverage. 23 There is no plausible basis In her opposition, Plaintiff relies on Rubin v. State Farm 24 Mut. Auto Ins. Co., 118 Nev. 299, 303-04 (2002) to argue that 25 “when a primary health insurer requires its insured to reimburse, 26 to incur, the cost of that care out of the proceeds of a third- 27 party settlement, the only reasonable expectation is that such 28 medical expenses were, as a result, ‘not covered’ under her 7 1 primary plan.” 2 a Nevada state court decision which analyzed only Nevada state 3 law. 4 the insured because it found the term “payable” ambiguous as to 5 whether it applied in a situation where workers’ compensation 6 benefits were reimbursed. 7 exclusion in the Policy excludes coverage for bills that are 8 “payable” and also “paid,” unlike in Rubin. 9 Further, the Policy here does not apply for bills unless they are Opp’n at 6. Rubin, 118 Nev. 299. Rubin is inapposite. First, it is Second, the court in Rubin found for Id. at 304. But here, the coverage Policy at 12. 10 “not covered” under the primary plan. 11 covered the bills by paying for them, even if Plaintiff later 12 reimbursed Kaiser through funds she got from a settlement. 13 ¶ 18. 14 this case fails. Policy at 4. Kaiser FAC 15 Plaintiff’s attempt to apply the reasoning in Rubin to Plaintiff also makes two other claims in her opposition. 16 First, Plaintiff seems to make an estoppel-type argument, 17 claiming that Defendant could not later reject Plaintiff’s claim 18 for coverage after asking her for more information in December 19 2015. 20 claim and the Court rejects it. 21 because Defendant’s claims rate rejection is high, there should 22 be further investigation of the expectations of an insured and 23 what Defendant contends the Policy covers. 24 cases Plaintiff provides in support of this argument examined 25 extrinsic evidence where, unlike here, the insurance contracts 26 were ambiguous. 27 Cal. App. 4th 1094, 1107 (1995); Employers’ Rein. Co. v. Sup. 28 Ct., 161 Cal. App. 4th 906, 921 (2008). Opp’n at 9. Plaintiff provides no legal support for this Second, Plaintiff argues that Id. But the two Cooper Cos. v. Transcontinental Ins. Co., 31 8 The Court also rejects 1 2 this argument. Finally, Plaintiff requests the opportunity to amend if the 3 Court concludes that she did not allege a viable UCL Claim. See 4 Opp’n at 15. 5 amendment would be futile. 6 Servs., 454 F.3d 1043, 1049 (9th Cir. 2006). 7 the Policy is unambiguous and allows Defendant to decline 8 coverage where a primary medical plan paid for the applicable 9 medical treatment, even where the Plaintiff later reimbursed the But the Court need not grant leave to amend where Deveraturda v. Globe Aviation Sec. As explained above, 10 primary medical plan from a settlement with a tortfeasor. 11 Plaintiff has pointed to no facts that suggest amendment could 12 rectify this problem. The Court denies Plaintiff’s request. 13 14 15 16 17 18 III. ORDER For the reasons set forth above, the Court GRANTS Defendant’s motion to dismiss with prejudice. IT IS SO ORDERED. Dated: January 8, 2018 19 20 21 22 23 24 25 26 27 28 9

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