Blue Shield of California Life & Health Insurance Company (Blue Shield) seeks a peremptory writ of mandate directing the trial court to reverse its order denying Blue Shield's motion for summary adjudication of plaintiff and real party in interest Myrna Yumiko Kawakita's tort cause of action for bad faith breach of a health insurance policy she obtained from Blue Shield. Blue Shield contends the cause of action is barred by the two-year limitations period for such claims, and was not extended to three
In July 2009, Myrna Kawakita sued Blue Shield, stating causes of action for breach of contract and tortious breach of the duty of good faith and fair dealing based on Blue Shield's August 2006 decision to rescind Kawakita's health insurance policy shortly after she received approval for, and then underwent, gastric bypass surgery. After her medical providers submitted claim forms for the procedure, Blue Shield looked at Kawakita's medical records and learned that Kawakita's application for coverage painted an inaccurate picture of her health.
The application said Kawakita was five feet eight inches tall and weighed 140 pounds. It also answered "no" to questions about the existence of certain medical conditions as part of her medical history. In fact, Kawakita was five feet six inches tall and weighed 307 pounds. Her medical records showed the existence of numerous ailments that were not listed on her application, including hypothyroidism, high cholesterol, insomnia, depression, and obesity, along with a physician's recommendation that she undergo a psychiatric evaluation and attend weight loss classes. Blue Shield rescinded primarily because of the height and weight discrepancies, but its rescission letter also noted the existence of Kawakita's various health problems.
Kawakita bought her policy through Blue Shield's alleged agent Steven M. Stendel, and claimed that Stendel was responsible for the misstatements in her application. She sued Blue Shield for breach of contract, tortious breach of the implied covenant of good faith and fair dealing, and declaratory relief.
Blue Shield brought a motion for summary adjudication of the tortious bad faith cause of action, contending it was barred by the two-year statute of limitations for such claims. (Code Civ. Proc., § 339, subd. 1; Love v. Fire Ins. Exchange (1990) 221 Cal.App.3d 1136, 1144, fn. 4 [271 Cal.Rptr. 246].) Insurance Code section 10350.11 requires that all health insurance policies include a provision stating, in essence, that all actions on a policy must be brought within three years of the date on which written proofs of loss must be furnished.
Although section 10350.11 prescribes the language to be used in a health insurance policy's provision concerning the time in which to sue on the policy, insurers are permitted to use different language that is not less favorable to an insured. (§ 10350.) Kawakita's opposition to the motion pointed out key differences between the statutorily required limitations provision and the language actually used by Blue Shield. Under the policy issued to Kawakita, the time to sue for any matters arising out of the policy could be brought within three years of the date when coverage for benefits was denied.
The trial court denied Blue Shield's summary adjudication motion. According to the trial court, the language in Blue Shield's limitation provision was "exactly the same" as that in section 10350.11. Because tortious bad faith claims were considered to be actions "on the policy" for purposes of the catchall, one-year limitations provision mandated by statute for fire insurance policies (§ 2071), the trial court reasoned that such claims were also on the policy for purposes of health insurance policies under section 10350.11. By parity of reasoning, the trial court found that bad faith tort actions against health insurers must be subject to a three-year limitations period under section 10350.11.
In addition to moving for summary adjudication, parties may move for summary adjudication of individual causes of action on the ground that they lack merit. (Code Civ. Proc., § 437c, subd. (f)(1).) The rules applicable to summary judgments apply equally to motions for summary adjudication. (Lunardi v. Great-West Life Assurance Co. (1995) 37 Cal.App.4th 807, 819 [44 Cal.Rptr.2d 56].) Summary judgment is granted when a moving party establishes the right to the entry of judgment as a matter of law. (Code Civ. Proc., § 437c, subd. (c).) In reviewing an order granting summary judgment, we must assume the role of the trial court and redetermine the merits of the motion. In doing so, we must strictly scrutinize the moving party's papers. The declarations of the party opposing summary judgment, however, are liberally construed to determine the existence of triable issues of fact. All doubts as to whether any material, triable issues of fact exist are to be resolved in favor of the party opposing summary judgment. While the appellate court must review a summary judgment motion by the same standards as the trial court, it must independently determine as a matter of law the construction and effect of the facts presented. (S.M. v. Los Angeles Unified School Dist. (2010) 184 Cal.App.4th 712, 716 [109 Cal.Rptr.3d 270].) Accordingly, we are not bound by the trial court's stated reasons and review only the ruling, not its rationale. (Law Offices of Dixon R. Howell v. Valley (2005) 129 Cal.App.4th 1076, 1092 [29 Cal.Rptr.3d 499].)
A defendant moving for summary judgment meets its burden of showing that there is no merit to a cause of action if that party has shown that one or more elements of the cause of action cannot be established or that there is a complete defense to that cause of action. (Code Civ. Proc., § 437c, subds. (o)(2), (p)(2).) If the defendant does so, the burden shifts back to the plaintiff to show that a triable issue of fact exists as to that cause of action or defense. In doing so, the plaintiff cannot rely on the mere allegations or denial of her pleadings, "but, instead, shall set forth the specific facts showing that a triable issue of material fact exists ...." (Id., subd. (p)(2).) A triable issue of material fact exists "if, and only if, the evidence would allow a reasonable trier of fact to find the underlying fact in favor of the party opposing the motion in accordance with the applicable standard of proof." (Aguilar v. Atlantic Richfield Co. (2001) 25 Cal.4th 826, 850 [107 Cal.Rptr.2d 841, 24 P.3d 493], fn. omitted.)
Relying primarily on federal court decisions, Blue Shield contends that section 10350.11 establishes nothing more than a contractual limitations period keyed to the filing of proofs of loss that has no effect on the statutory two-year limitations period (Code Civ. Proc., § 339, subd. 1) for tortious bad faith claims. Instead, Blue Shield contends it applies to only actions on the policy, which means only claims for breach of contract or for contractual bad faith, not for tortious bad faith.
The first of these is Wetzel, supra, 222 F.3d 643, which concerned the statute of limitations in an action under the Employee Retirement Income Security Act of 1974 (29 U.S.C. § 1001 et seq. (ERISA)). Because ERISA does not contain a statute of limitations, the federal courts look to the most analogous state law limitations period in the state where the action is brought. (Wetzel, supra, at pp. 646-647.) In Wetzel, the Ninth Circuit overruled its earlier decision in Nikaido v. Centennial Life Ins. Co. (9th Cir. 1994) 42 F.3d 557, which had held that for an ERISA action brought in California arising from a health insurance plan, section 10350.11 provided the most analogous limitations period. Wetzel said that California law treated policy provisions required by section 10350.11 as a contractual limitations period that was
In Flynn v. Paul Revere Ins. Group (9th Cir. 2001) 2 Fed.Appx. 885 (Flynn), the Ninth Circuit applied Wetzel and held that a policyholder's tortious bad faith claim against a health insurer was subject to the statutory two-year limitations period for such claims because section 10350.11 established nothing more than a contractual limitations period that operates separate and apart from the ordinary statutory limitations period. Accordingly, the Flynn court held, both the statutory and contractual limitations periods had to be satisfied. (Flynn, at p. 886.)
An earlier decision by a California appellate court suggests a similar result. In NN Investors Life, supra, 208 Cal.App.3d 1070, the court affirmed a summary judgment for a health insurer because the plaintiff insured sued
None of these decisions concerned policy language that deviated from section 10350.11. Assuming for argument's sake that Blue Shield's interpretation of section 10350.11 is correct and that inclusion of section 10350.11's language in a policy does not lengthen the two-year statute of limitations for tortious bad faith claims, as we explain below, we conclude that the statutory language does not apply to Blue Shield's policy.
Under the heading
This is far different from the terms of section 10350.11, which states that no action "to recover on this policy" shall be brought three years "after the time written proof of loss is required to be furnished." Blue Shield contends that actions on a policy are limited to the payment of benefits under contract law theories.
In essence, the policy told Kawakita that any matter arising out of the plan had to be brought within three years of the time her claim was denied. The
Blue Shield challenges this interpretation on three grounds: (1) because the provision is still tied to filing proofs of claim, and Kawakita never did so, she may not take advantage of the provision; (2) evidence that Blue Shield intended to waive the two-year limitations period for tortious bad faith claims is not in the record; and (3) the phrase "any other matter arising out of this Plan" must be construed with reference to the more limited class of occurrences listed before it, which are exclusively contract-related claims. We take each in turn.
The first is a variant of Blue Shield's contention that section 10350.11 is nothing more than part of a statutory proof of loss framework for contract claims which are brought on the policy, and therefore does not apply at all to tortious bad faith claims. Under Blue Shield's policy, when a preferred provider supplies medical treatment, the provider typically files a claim with Blue Shield. The policy states that an insured files a proof of claim when a preferred provider fails to bill Blue Shield, or when the insured receives treatment from a nonpreferred provider. During oral argument, counsel for Blue Shield contended that the policy's limitation provision did not apply because Kawakita's providers submitted claims to Blue Shield, meaning that Kawakita herself never filed the proof of claim that was required to trigger the three-year period.
This contention might make sense if we were limited to construing section 10350.11, and if Blue Shield's interpretation of that provision were correct. As already discussed, however, Blue Shield's use of more favorable language has taken this matter outside the realm of statutory interpretation and into that of contract interpretation. Therefore, we construe the policy as a reasonable
Under the heading, "Notice and Proof of Claim," the policy provides the mechanism by which an insured submits a proof of claim. Blue Shield contends this means that only an insured may do so, and that its limitation provision applies only in that instance. However, under the caption "Your Blue Shield Life Active Start Plan 25 and How to Use It—," the policy states:
We distill this language as follows. First, the policy states that claims are submitted in two ways—by both the insured and by preferred providers. No meaningful distinction between the two claims submission mechanisms is evident. Second, the policy goes on to state that claims—which now presumably includes those made by a provider or a policyholder—are paid upon "proper written proof." The policy's limitation provision then states that an action may not be brought until 60 days after "written proof of claim" has been filed. We conclude that a reasonable insured would read these provisions together to mean that all claims, whether made by the insured or a preferred provider, require written proof, and that the time to sue begins to run after a claim is submitted in either manner.
As to the second, Blue Shield cites inapplicable decisions concerning the type of proof required to show that a party either waived or was estopped from relying on certain contract provisions. Blue Shield also relies on Code of Civil Procedure section 360.5, which provides that the statute of limitations may not be waived for longer than four years, and only then by an agreement signed by the waiving party. It is not clear to us that this statute applies to a contract provision that does not waive the statute of limitations, but instead merely purports to fix it for actions arising from the agreement. Assuming for the sake of argument that Code of Civil Procedure section 360.5 does apply in this setting, we conclude that the policy's extended limitations clause complies with that provision because it is in writing and the policy was signed by both the secretary and president of Blue Shield.
The petition is denied. Real party in interest shall recover her appellate costs.
Flier, J., and Grimes, J., concurred.
Our decision addresses the statute of limitations and related contract provision only. We express no opinion on the merits of Kawakita's claims.
Blue Shield contends, for the first time on appeal, that there is no evidence it ever received approval from the Insurance Commissioner to use language that differed from section 10350.11. Because Blue Shield did not raise the issue in the trial court, it was waived. (North Coast Business Park v. Nielsen Construction Co. (1993) 17 Cal.App.4th 22, 28-31 [21 Cal.Rptr.2d 104].) Should such evidence be introduced at trial, we express no opinion on its effect.
Furthermore, Blue Shield's interpretation would leave policyholders without guidance as the limitation period for suits brought when claims filed by preferred providers are denied. The result of such an interpretation is unclear, but, arguably, the three-year limitation period would evaporate, leaving the statutory two-year period for tortious bad faith claims, while also reinstating the statutory four-year period for breach of contract claims. In other words, there would be a contractual limitations period of three years based on denied claims when those claims were for services rendered by a nonpreferred provider and the insured filed the claim, and some unstated limitations period for denied claims for services rendered by a preferred provider and the provider filed the claim. As Blue Shield itself noted at oral argument, such a result would be nonsensical.