- LC 3365.4 Barred Fatally Injured School Volunteer Survivors' Lawsuiton March 13, 2025 at 2:41 PM
Dublin Unified School District (DUSD) held a distribution event on March 24, 2021 at one of its middle schools for the “Farmers to Families Food Box Program,” which provided fresh food to families negatively affected by the COVID-19 pandemic. Catherine Kuo volunteered at this event.
While she was loading a food box into the rear of one vehicle, another vehicle entered the parking lot and pulled up behind. A DUSD employee approached the second car and instructed the driver to open the rear hatch of the vehicle so he could load a food box into the rear cargo area of that vehicle. The driver suddenly drove forward, crushing Kuo between the two vehicles. Kuo was transported to a medical center and died later that day.
Kuo’s family members and estate filed a complaint against DUSD asserting negligence and premises liability causes of action. The complaint alleged that DUSD was negligent by failing to implement basic safety protocols at the event, failing to communicate safety protocols to volunteers and others, and failing to train and/or supervise employees who were organizing and coordinating the event. It also alleged that DUSD had created a dangerous condition of public property by failing to implement such safety protocols.
DUSD moved for summary judgment, arguing that Labor Code section 3364.5 barred plaintiffs’ claims. Section 3364.5 is part of the Workers’ Compensation Act (§ 3201 et seq.). It provides that “a volunteer, unsalaried person authorized by the governing board of a school district or the county superintendent of schools to perform volunteer services for the school district or the county superintendent shall, upon the adoption of a resolution of the governing board of the school district or the county board of education so declaring, be deemed an employee of the district or the county superintendent for the purposes of this division and shall be entitled to the workmen’s compensation benefits provided by this division for any injury sustained by him while engaged in the performance of any service under the direction and control of the governing board of the school district or the county superintendent.” (§ 3364.5.)
In support of its motion, DUSD submitted Resolution 2011/12-30 (Resolution) passed and adopted by its board of trustees in 2012. DUSD also submitted the memorandum of coverage from the Protected Insurance Program for Schools applicable to the time period of the March 24, 2021 incident.
The trial court granted DUSD’s motion for summary judgment. It determined that death “falls into the category of an injury according to its plain meaning.” And while finding no ambiguity in the term, the court noted that the legislative history of the statute - evidencing an intent to provide school volunteers with the same protection as employees - supported this reading. The court concluded that section 3364.5 defeated its jurisdiction. Judgment was entered in favor of DUSD and against plaintiffs.
The Court of Appeal affirmed the summary judgment in the published case of Kuo v. Dublin Unified School Dist - A169912 (March 2025).
This appeal presented two questions of statutory interpretation: whether the term “any injury” covers fatal injuries like the one Kuo sustained here, and whether DUSD volunteers were “deemed” employees under section 3364.5.
The Court of Appeal wrote "Section 3364.5 provides entitlement to workers’ compensation for “any injury” sustained by a school volunteer while engaged in the performance of service. We conclude that fatal injuries unambiguously fall into the category of “any injury” according to its plain meaning."
Plaintiffs argue that DUSD volunteers were not “deemed” employees under section 3364.5 for two reasons: (1) DUSD’s Resolution did not use the term “deemed,” and (2) DUSD did not treat its volunteers as employees. The Court of Appeal wrote "Neither is persuasive."
"Nothing in the statute supports plaintiffs’ position that a resolution must explicitly use the word “deemed” to trigger section 3364.5. Section 3364.5 requires only that the governing board adopt a resolution “so declaring.” DUSD did exactly that, adopting a resolution stating, “in accordance with Section 3364.5 of the Labor Code, volunteers shall be entitled to Workers’ Compensation benefits for any injury sustained by him/her while in the performance of any service under the direction and control of the District Superintendent.” We do not read into the statute any additional requirement to use magic words, as such an interpretation would defy section 3202’s command that the WCA be liberally construed."
- Three Face Charges for Fraudulent LA Wildfire Benefit Claimson March 13, 2025 at 2:41 PM
Three defendants have been charged in recent days with fraudulently seeking federal disaster relief funds by falsely claiming their properties were damaged by the Eaton and Palisades wildfires when in fact they did not have an interest in the affected property or the property was not affected by either fire, the Justice Department announced today. The three defendants – two in Southern California and one in Texas – were arrested this week after being charged with defrauding the Federal Emergency Management Agency.
The allegedly false claims were made in the wake of the Eaton and Palisades fires that started on January 7. Together, the wildfires burned nearly 60,000 acres, destroyed more than 16,000 structures, and resulted in the deaths of 29 people. As a result, the President approved a Major Disaster Declaration, which prompted FEMA to develop a program to provide financial assistance to fire victims.
FEMA offered various forms of relief, a one-time payment of $750, up to $43,600 for “other needs” assistance, and housing assistance for up to 18 months. Homeowners are also potentially eligible for additional relief of up to $43,600 for home repair.
The fraud alleged in the three cases include payment of “other needs assistance” based on false claims of damage to personal property, lost vehicles, and medical and relocation expenses.
Joyce Turner, 55, of Rosharon, Texas, was arrested Tuesday after being charged Friday in a criminal complaint with fraud in connection with major disaster or emergency benefits.
Turner allegedly submitted an application claiming her home had been destroyed in the Eaton fire, but she appears never to have lived in California and in fact had no connection to the address she claimed was destroyed in the fire. Instead, she allegedly forged a lease making it look like she lived there, and she received more than $25,000 from FEMA because of the fraudulent submissions.
“Turner submitted at least ten other applications to FEMA for disaster relief (so eleven total) related to seven other federally declared disasters, e.g., Hurricane Katrina (2005), Hurricane Ike (2008), Hurricane Isaac (2012), Hurricane Harvey (2017), and Hurricane Beryl (2024), and otherwise has a criminal history showing previous arrests and convictions for fraud offenses,” the affidavit states.
Turner is scheduled to make her initial appearance today in United States District Court in the Southern District of Texas and is expected to appear in the Central District of California in the coming weeks.
Tyrone D. Barnes Jr., 38, of Paramount, was arrested Tuesday after being named in an indictment charging him with making false claims that was returned by a federal grand jury on February 21. The indictment alleges that Barnes submitted a disaster relief claim to FEMA for an Altadena property owned by other individuals who did not know Barnes. The true owners of the property contacted FEMA about potential assistance, which is when they learned another person had already submitted an application in relation to their property.
Barnes is expected to make his initial appearance this afternoon in United States District Court in downtown Los Angeles.
Hedeshia Robertson, 36, of Lakewood, was arrested on Tuesday after being charged in a criminal complaint filed Monday. Robertson allegedly filed a fraudulent application for FEMA benefits on January 28, seeking benefits related to a damaged residence in the Pacific Palisades that she did not own, did not rent, and in which she did not reside or work. As a result of her fraudulent application, Robertson obtained approximately $24,899 in FEMA benefits to which she was not entitled. At the time of her arrest, Robertson also allegedly attempted to obtain additional FEMA benefits for a purported property lease in San Francisco. She is due to make an initial appearance in court this afternoon.
The charge of fraud in connection with major disaster or emergency benefits carries a statutory maximum sentence of 30 years in federal prison. The charge of false, fictitious, or fraudulent claim against the United States carries a statutory maximum sentence of five years in federal prison.
- SafeLite Resolves IFPA Auto Insurance Fraud Case for $31Mon March 12, 2025 at 2:55 PM
The California Insurance Fraud Prevention Act (IFPA) is designed to protect both consumers and the integrity of the insurance industry within the state. Its primary goal is to combat and prevent fraudulent activities that exploit insurance systems, ensuring that trust and fairness remain central to these services.
What helps make the IFPA effective are its whistleblower provisions. Individuals who uncover fraudulent activities have the opportunity to file litigation against violators and receive a share of recovered funds as a reward for their courage.
An recent IFPA case filed in California involved serious allegations of unethical billing practices by Safelite Group Inc., Safelite Fulfillment inc., dba Safelite AutoGlass, a leading company in auto glass repair and replacement. A former employee, Brian Williams, stepped forward as a whistleblower, filing insurance fraud lawsuits in California and Illinois. He was last employed by Safelite as aproduct development and strategy manager
The Illinois Insurance Claims Fraud Prevention Act (IICFPA) was also central to the Safelite case. This Illinois law also allows whistleblowers to file lawsuits on behalf of the state against entities suspected of submitting false claims to insurers.
According to the allegations contained in Williams' Second Amended Complaint filed in the San Mateo Superior Court last July, to recover damages and civil penalties on behalf of the People of the State of California, arising from an alleged insurance fraud scheme planned and carried out by Safelite.
According to Williams, Safelite consistently billed insurance companies for high-quality OEM (Original Equipment Manufacturer) parts - components trusted for their durability and performance. However instead of using these premium parts, Williams alleged Safelite often replaced them with cheaper, generic alternatives known as "universal molding." Moldings are a rubber or plastic trim, most commonly black in color, that usually run along either the top or the top and sides of, and at times even around, the glass of a vehicle. Molding provides insulation and noise reduction while holding the window in place securely and safely.
The complaint contained examples of invoices sent to Safeco, Farmers and State Farm Insurance, charging for a higher grade molding than the universal moulding. And went on to allege that from "at least 2015 through 2020, Safelite engaged in this practice of using universal molding but charged insurance companies and others for part-specific molding on over 1 million vehicles. In 2019 and 2020 alone, Safelite charged insurance companies and others for part-specific molding, but used universal molding to outfit the vehicles, for over 255,000 vehicles, over 13,850 of which were for vehicles whose glass was replaced in California."
"Safelite AutoGlass was systematically billing for OEM or aftermarket parts when universal moldings were actually used in their place. Furthermore, the data showed that this sort of billing was happening across all insurance clients and customers billed via account, including government agencies, commercial accounts, and fleet accounts."
Another alleged scheme involved additional charges imposed by Safelite during the COVID-19 pandemic. Customers were reportedly billed for cleaning services intended to ensure safety and hygiene. However, the lawsuits alleged that these services were inconsistently applied and offered to only a small fraction of customers, raising questions about the company’s billing practices.
According to news sources SafeLite has agreed to a $31 million settlement to resolve the claims. Safelite did not admit to any wrongdoing.
- ER Physician Staffing Firms Face Financial Difficulty & Bankruptcyon March 12, 2025 at 2:54 PM
NES Health, a physician-led staffing firm, is headquartered in Tiburon, California. They specialize in providing physician staffing and healthcare management services, focusing on areas like emergency medicine, hospital medicine, post-acute care, and telemedicine. Their mission has been to support hospitals with tailored solutions to improve patient care, operational efficiency, and overall healthcare delivery.
NES Health was founded by Dr. Allan Rappaport, initially focusing on emergency medicine. Over the years, it expanded its scope to include hospital medicine, post-acute care, and telemedicine. The company prided itself on being physician-owned and physician-led, emphasizing a commitment to quality care and operational efficiency.
In California, NES Health worked with hospitals like Seton Medical Center in Daly City and Sierra View Medical Center in Porterville where they staffed emergency department physicians.
However, financial difficulties in late 2024 led to unpaid wages for physicians at several hospitals, including Seton Medical Center hat ultimately led to its Chapter 7 bankruptcy filing last month. Here are the key challenges they encountered:
- - Cash Flow Issues: The company ran out of available cash and funding, which left them unable to pay their physicians, vendors, and contractors. This included unpaid wages for emergency department physicians at multiple hospitals.
- - Malpractice Coverage Lapse: NES Health could not afford to maintain malpractice tail coverage for its physicians, which is a critical safety net for healthcare providers.
- - Delayed Payments: Physicians and staff experienced delays in receiving their payments, with some going unpaid for up to 2.5 months. This created uncertainty and financial strain for the workforce. - - High - - Liabilities: The company reported liabilities ranging from $10 million to $50 million, far exceeding its estimated assets of $1 million to $10 million.
- - Operational Shutdown: In November 2024, NES Health announced its decision to wind down operations and cease doing business, citing the inability to sustain its financial obligations.
These challenges were compounded by broader industry trends.Several physician staffing companies have faced financial difficulties in recent years, including those operating in California. Here are some notable examples:
- - TeamHealth: This national staffing company has faced lawsuits and financial challenges related to billing practices and disputes with insurers. While they continue to operate, these issues have strained their financial stability.
- - Envision Healthcare: Another major player in the staffing industry, Envision Healthcare, has struggled with debt and operational challenges. They filed for Chapter 11 bankruptcy in 2023, citing financial pressures from declining reimbursements and increased operational costs.
- - American Physician Partners: This company ceased operations in 2023 due to financial difficulties, leaving many hospitals scrambling to find replacement staffing solutions.
These challenges reflect broader trends in the healthcare staffing industry, including rising operational costs, reimbursement pressures, and the impact of regulatory changes.
- Court of Appeal Allows Case Against DHS for Underground Regson March 11, 2025 at 5:19 PM
Plaintiff California Healthcare & Rehabilitation Center and more than 20 similar California based skilled nursing facilities operate subacute units. Subacute units provide services to patients requiring less intensive services than those provided in an acute care hospital but more intensive than those provided to general patients in skilled nursing facilities. In addition to the general subacute services provided, plaintiffs also provide ancillary services including physical therapy, speech therapy, occupational therapy, and certain medical supplies.
Plaintiffs participate in Medicare and Medi-Cal programs and have received payments from both. Under California Code of regulations, title 22, sections 51005 and 50761, Medi-Cal is mandated to be the payor of last resort, meaning a facility has to seek reimbursement from other coverage, including Medicare, before seeking reimbursement from Medi-Cal.
“Medi-Cal has a different payment process than Medicare does. Medi-Cal generally pays an all-inclusive, facility-specific, per-diem rate to [skilled nursing facilities]. The per-diem rates are calculated based on actual costs that the facility reported to the Department. Medicare, on the other hand, pays facilities on a per-item basis. If [a skilled nursing facility] patient has both Medi-Cal and Medicare, and Medi-Cal makes a payment on a per-diem basis and Medicare makes a payment on a per-item basis, there may be double payment for the same ancillary services.
Plaintiffs filed a petition for traditional writ of mandate pursuant to Code of Civil Procedure section 1085 and a complaint for declaratory relief pursuant to section 1060, alleging the State Department of Health Care Services and Michelle Baass (in her capacity as Director of DHS) violated a ministerial duty and adopted a regulation in violation of the Administrative Procedure Act (Gov. Code, § 11340 et seq.) by utilizing an overpayment formula based on the amount Medicare paid plaintiffs for ancillary services instead of on the amount Medi-Cal overpaid for those services.
The trial court sustained the Department’s demurrer without leave to amend, finding plaintiffs’ claim was not cognizable in a traditional writ of mandate proceeding and, alternatively, that plaintiffs failed to state a claim the Department violated a ministerial duty or adopted an underground regulation. Separately, the trial court denied plaintiffs’ motion to compel discovery of various documents the Department utilizes while training its employees because it found the documents were privileged.
The Court of Appeal reversed the judgment of dismissal and affirmed the trial court’s order denying plaintiffs’ motion to compel in the published case of Cal. Healthcare & Rehabilitation Center v. Baass - C098043 (March 2025).
Plaintiffs’ petition alleges the Department uses an overpayment formula it adopted contrary to law and in contravention of its ministerial duties and requests a declaration stating so, as well as an injunction against the Department from utilizing the overpayment formula in the future.
State agencies must adopt regulations following the procedures established in the Administrative Procedure Act. These procedures, among other things, require state agencies to provide the public with notice of proposed regulations (Gov. Code, §§ 11346.4, 11346.5), give interested parties an opportunity to comment on proposed regulations (Gov. Code, § 11346.8), and respond in writing to submitted written comments (Gov. Code, §§ 11346.8, 11346.9). Regulations wrongly adopted outside these procedures are known as underground regulations and are void. (Tidewater Marine Western, Inc. v. Bradshaw (1996) 14 Cal.4th 557, 572-573 (Tidewater); see Cal. Code Regs., tit. 1, § 250, subd. (a)(1).)
Determining whether the Department’s purported overpayment formula is lawful and complies with its ministerial duties is an issue reserved for traditional writ of mandate proceedings that review the propriety of quasi-legislative acts and ministerial determinations. (See California Water Impact Network v. Newhall County Water Dist. (2008) 161 Cal.App.4th 1464 at p. 1483.) Accordingly, plaintiffs’ petition is cognizable under section 1085.
Plaintiffs argue the petition sufficiently provides they did not need to exhaust their administrative remedies, as well as states a claim under sections 1085 and 1060 because the Department’s use of the overpayment formula violated a ministerial duty and constituted an underground regulation.
The Court of Appeal agreed that plaintiffs had no administrative remedies to exhaust and that they stated a claim the overpayment formula constitutes an underground regulation.
- Physician & SoCal Pharmaceutical Company VP Pleads Guiltyon March 11, 2025 at 5:19 PM
George Demos, then-vice president at San Diego-based Acadia Pharmaceuticals Inc., pleaded guilty in federal court to illegally selling 60,000 company shares, thus avoiding a $1.3 million loss by acting on insider knowledge about the labeling process for a prescription drug with the Food and Drug Administration (FDA).
Demos, a medical doctor who was the Vice President of Drug Safety and Pharmacovigilance and member of the drug label team at publicly-traded Acadia, admitted that he was able to avoid the loss by dumping his shares just two hours before negative news about the labeling process became public.
Through his positions, Demos had access to material information belonging to Acadia, including the drug approval and labeling process with the FDA, before the information was released to the investing public. As an employee of Acadia, Demos was subject to an insider trading policy that prohibited trading in company stock on the basis of material nonpublic information.
As of 2021, Acadia’s only fully FDA-approved pharmaceutical product was Pimavanserin, sold under the brand name Nuplazid, for the treatment of Parkinson’s disease psychosis. Demos admitted that in 2020, he learned inside information that Acadia had applied for FDA approval for the expansion of the label for Nuplazid to treat dementia-related psychosis. Expanding the label was expected to generate significant revenue for Acadia because it would allow the drug to treat a larger patient population.
Demos also admitted, however, that in March 2021, he learned additional inside information that discussions with the FDA had stalled, indicating a problem with the label. Acting on that inside information, Demos sold more than 60,000 shares of Acadia for $2,833,856.15 - less than two hours before Acadia issued a press release announcing deficiencies in its drug application with the FDA, preventing labeling discussions. Demos admitted that based on the inside information, he sold his Acadia stock for $46.61 per share, avoiding the 45 percent drop in stock price, to $25.02, that occurred the next day after the press release was issued to the public. Through this illegal trading, Demos avoided a loss of $1,313,263.
As part of his plea, Demos agreed to forfeit $1,313,263 – the loss he avoided through his insider trading. Demos is scheduled to be sentenced on May 30, 2025, at 9 a.m. before U.S. District Judge Robert Huie.This case is being prosecuted by Assistant U.S. Attorney Janaki G. Chopra.
- Cooperation & Assistance of Insured Clause Defends $9M Verdicton March 10, 2025 at 1:26 PM
On January 13, 2017, an automobile accident occurred between Dennis Perez, who was insured by Farmers Direct Property and Casualty Insurance Company and Victor Montez. Charged for driving under the influence and causing bodily injury to another Perez pleaded nolo contendere and served two years in jail. The Montezes alleged Perez’s “legal intoxication” caused the accident and the resulting “severe injuries” to Victor Montez, but Perez claimed that he unexpectedly hit a puddle, causing his vehicle to hydroplane into oncoming traffic.
On March 10, 2017, Victor Montez sent Farmers Direct a handwritten settlement demand letter, to indicate that he sought to settle for the full Policy amount, inquire whether Perez was “doing anything or going anywhere for his job” at the time of the accident, and determine if Perez had “any other insurance policies . . . .” As of May 18, 2017, Farmers Direct told the Montezes that it could not reach Perez “to obtain an affidavit of no other insurance . . . .” However it did offer to settle for the $25,000 policy limit.
Nearly a year later, the Montezes filed their underlying tort action against Perez in state court on May 10, 2018. Farmers Direct appointed counsel to defend Perez in the lawsuit. Perez’s appointed counsel subsequently asserted several defenses, but Perez was uncooperative with his own defense by failing to communicate with his counsel, who eventually retained a private investigator to locate Perez.
On June 15, 2021, the state court allowed Farmers Direct to intervene on behalf of Perez in the underlying tort action after previously denying its request. Farmers Direct incurred over $100,000 in defense fees, to intervene on behalf of Perez ahead of trial in the underlying tort action.
On November 9, 2021, Farmers Direct filed its declaratory judgment action in the federal district court, seeking a declaration that Perez breached the Policy’s provision relating to duties after loss (“Cooperation Clause”), and, in turn, that Farmers Direct no longer has a duty to defend or indemnify Perez in the underlying tort action.
On February 23, 2022, the federal district court entered Judgment, declaring that Farmers Direct: owes no continuing duty to defend and owes no duty to indemnify Perez in connection with the underlying [tort] action . . . because Perez’s breach of the Policy’s Cooperation Clause excuses further performance by Farmers Direct.
During trial of the underlying tort action in state court, Farmers Direct was not able to effectively raise liability defenses, including the theory that Perez hydroplaned after hitting a puddle, because of Perez’s lack of cooperation. On July 28, 2023, the state court entered a tort judgment against Perez of $8,862,730.00 in damages, $881,014.41 in costs and fees, and $3,205,151.67 in prejudgment interest were entered against Perez on November 9, 2023. On August 23, 2023, Farmers Direct paid the $25,000 Policy limit in partial satisfaction of the judgment.
On September 1, 2023, the Montezes filed a motion in Farmers Direct’s declaratory judgment action in federal court to intervene and to vacate the Judgment finding Farmers Direct owes no duty to indemnify Perez on several grounds, including that the Judgment “is void because the [district] [c]ourt lacked subject matter jurisdiction.” The district court agreed with the Montezes in its October 6, 2023 Order vacating the Judgment for lack of subject matter jurisdiction because the amount in controversy was the Policy’s $25,000 face amount, which was less than the over $75,000 statutory minimum.
The 9th Circuit Court of Appeals reversed in the published case of Farmers Direct Property and Casualty Insurance Company v Montez - 23-3320 (March 2025) The 9th Circuit held that the district court erred when it decided that the value of the declaratory judgment action.
In its federal Complaint for Declarative relief Farmers Direct alleged that the Montezes, as the “underlying plaintiffs now contend they are entitled to hundreds of millions of dollars in damages and further contend that Farmers Direct is liable for such damages notwithstanding its Policy limits.” The Montezes’ state court demand served as the basis for Farmers Direct’s claim that the amount-in-controversy requirement was satisfied in federal court, and a federal plaintiff’s “claim in excess of the requisite amount, made in good faith in the complaint, satisfies the jurisdictional requirement.”
The Montezes concede that in their underlying tort action against Perez they “alleged they were seeking for hundreds of millions in damages.” The Montezes cannot now dispute Farmers Direct’s “assumption that the value of . . . their underlying tort claims against” Perez was greater than $75,000, given that they once sought hundreds of millions in damages.
"The judgment was not void because there was at least an “arguable basis” that the amount in controversy was satisfied by considering either the potential excess liability of the underlying tort claim or Farmer Direct’s anticipated future defense fees and costs, or both."
- Failure to Oppose Summary Judgment is Good Cause to Grant iton March 10, 2025 at 1:26 PM
Melissa Mandell-Brown filed a complaint against her employer Novo Nordisk, Inc. asserting 16 causes of action, including statutory claims for discrimination, sexual harassment, and retaliation under FEHA and the Labor Code and common law claims for breach of contract, wrongful termination, and intentional infliction of emotional distress.
On May 18, 2022, defendants filed their motion for summary judgment or, in the alternative, summary adjudication and argued that none of plaintiff’s causes of action survived summary judgment. The supporting separate statement included 161 undisputed facts. Defendants also submitted an attorney declaration authenticating 25 discovery exhibits and six witness declarations authenticating another 51 exhibits and containing detailed explanations of the non-discriminatory and non-retaliatory reasons for the elimination of plaintiff’s job position. The notice of motion set the hearing date for August 3, 2022, with a trial date then pending for October 4, 2022.
Two days before the hearing on the motion, on August 1, 2022, plaintiff, who had not filed an opposition to the motion, applied ex parte to continue the hearing. The trial court granted the application, setting the hearing for September 16, 2022, and continuing the trial date to November 8, 2022.
On September 14, 2022, plaintiff, who still had not filed her opposition, again applied ex parte to continue the hearing, and the trial court granted the application, setting the continued date for October 14, 2022, and continuing the trial until December 6, 2022. At the October 14, 2022, continued hearing on the motion, plaintiff did not file an opposition or separate statement, request a third continuance, or appear at the hearing. The trial court denied the third continuance. And it also issued a minute order granting defendants’ motion for summary judgment based upon no opposition, "plaintiff is conceding that the motion should be granted."
The Court of Appeal affirmed the judgment for defendant in the published case of Mandell-Brown v. Novo Nordisk Inc. et al. - B326147 (March 2025)
The requirements for opposing a motion for summary judgment or adjudication are set forth in CCP section 437c, subdivision (b)(3), which provides that: “The opposition papers shall include a separate statement that responds to each of the material facts contended by the moving party to be undisputed, indicating if the opposing party agrees or disagrees that those facts are undisputed. The statement also shall set forth plainly and concisely any other material facts the opposing party contends are disputed. Each material fact contended by the opposing party to be disputed shall be followed by a reference to the supporting evidence. Failure to comply with this requirement of a separate statement may constitute a sufficient ground, in the court’s discretion, for granting the motion.”
Separate statements are “required, not discretionary, on the part of each party, and the statutory language makes the failure to comply with this requirement sufficient grounds to grant the motion.” (Whitehead v. Habig (2008) 163 Cal.App.4th 896, 902.)
Further, the trial court here granted plaintiff two continuances to file her opposition, which required two continuances of the trial date. Notwithstanding the additional time the court afforded her to file opposition papers, plaintiff failed to submit points and authorities addressing defendants’ evidence as it related to the elements of her claims, any declarations presenting disputed factual issues, or a separate statement to assist the court in parsing which of the 161 facts asserted and supported by defendants’ evidence she disputed.
"Under these circumstances, we conclude the trial court did not abuse its discretion in granting the motion pursuant to section 437c, subdivision (b)(3)."
- Proposed Law Mandates Healthcare Insurance Denial Rate Reportingon March 6, 2025 at 11:53 AM
Health insurer claim denial rates have been a significant concern in recent years. In 2024, Experian Health reported that 38% of healthcare providers experienced claim denials for at least one in ten claims, with some organizations seeing denial rates of more than 15%. The denial rates for insurers of qualified health plans (QHPs) sold on HealthCare.govwere also notable, with 19% of in-network claims and 37% of out-of-network claims being denied, resulting in an average denial rate of 20% for all claims.
The variation in denial rates among insurers is substantial. For instance, UnitedHealthcare denied nearly one-third of claims, making it the company with the highest denial rate among those offering plans on Affordable Care Act exchanges. Common reasons for claim denials include missing or inaccurate data, lack of prior authorization, and excluded services.
Despite the high denial rates, consumers rarely appeal denied claims. In fact, fewer than 1% of denied claims were appealed, and insurers upheld 56% of those appeals. These statistics highlight the ongoing challenges faced by healthcare providers and patients in dealing with claim denials.
The government has taken several steps to address the issue of health insurer claim denial rates. Here are some key actions:
- - Transparency Requirements: The Affordable Care Act (ACA) mandates that insurers report transparency data for all non-grandfathered health plans sold on and off the Marketplace, including fully-insured and self-insured employer group health plans. This data is available to federal and state insurance regulators and the public.
- - Data Analysis and Reporting: The Centers for Medicare and Medicaid Services (CMS) analyze and release data on claims denials and appeals for non-group qualified health plans (QHPs) offered on HealthCare.gov.This data helps identify patterns and areas for improvement.
- - Policy Recommendations: The ERISA Advisory Council (EAC), a body appointed by the Secretary of Labor, has made 12 policy recommendations to improve the claims denial and appeals process. These recommendations aim to address dubious denial processes and make the appeals process less difficult for consumers.
- - Consumer Protection: The government continues to monitor and enforce regulations to protect consumers from unfair claim denials. This includes ensuring that insurers comply with transparency requirements and addressing any violations.
And now in California Assembly Bill 682, proposed new legislation authored and introduced by Assemblymember Liz Ortega of Hayward, would mandate public reporting on the denials of insurance claims for California’s patients.
The new bill seeks to mandate collection and public reporting of health insurance claims denial information for each health plan regulated by the California Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI).
The information collected and reported would include the number of claims denied, the costs of denied claims, whether or not artificial intelligence was used in the decision, and — significantly — reasoning for denying claims, such as a lack of prior authorization or an out-of-network provider.
California Nurses Association (CNA) and its more than 100,000 members across California today shared their support for Assembly Bill 682 in its press release.
- Ortho Surgeon Inflation Adjust Pay Over 20 Years Declined 38%on March 6, 2025 at 11:53 AM
Healthcare finance in the United States is continually changing with increased consolidation of healthcare organizations, fluctuating reimbursement cycles, and shifting institutional and federal policy. The economics of practicing medicine are dynamic and challenging relative to other professions.
The purpose of new a study just published in the Journal of Arthroplasty (Pereira DE, et al. J Arthroplasty. 2025;doi:10.1016/j.arth.2025.02.012) was to analyze compensation trends in orthopaedic surgery over the past 20 years compared to other professions.
To accomplish this purpose the authors reviewed income data for orthopaedic surgeons and other professions every five years from 2000 to 2020 which was collected from the United States Bureau of Labor Statistics and peer-reviewed literature. Income data were adjusted for inflation and analyzed to identify trends in compensation.
The analysis showed that the rate of absolute income trajectory over two decades for orthopaedic surgeons when adjusted for inflation was -38%. Outside of healthcare professions, economists, lawyers, and engineers saw some of the highest increases with inflation-adjusted increases at +31, 26, 24%, respectively. Orthopaedic surgeon salary rates declined the most of all professions analyzed, including all healthcare workers.
As a result of this analysis, the authors concluded that the adjusted orthopaedic surgeon compensation has declined significantly in the two decades between 2000 to 2020. Compared to other high-skilled professions, orthopaedic compensation showed the greatest decline in adjusted rates over time.
Thus they concluded that "This trend carries major implications for the future of the field, potentially affecting recruitment, satisfaction, burnout, and patient access to care. It underscores the need for a re-evaluation of compensation models in orthopaedic surgery to ensure sustainability."
They also noted that inflation, rising interest rates, staff shortages, policy changes, decreases in per-case reimbursement, financial burdens of Medicare and Medicaid patients, as well as increasing year-over-year expenses, may play a role in compensation decreases for orthopedic surgeons.
- LC 3365.4 Barred Fatally Injured School Volunteer Survivors' Lawsuiton March 13, 2025 at 2:41 PM
Dublin Unified School District (DUSD) held a distribution event on March 24, 2021 at one of its middle schools for the “Farmers to Families Food Box Program,” which provided fresh food to families negatively affected by the COVID-19 pandemic. Catherine Kuo volunteered at this event.
While she was loading a food box into the rear of one vehicle, another vehicle entered the parking lot and pulled up behind. A DUSD employee approached the second car and instructed the driver to open the rear hatch of the vehicle so he could load a food box into the rear cargo area of that vehicle. The driver suddenly drove forward, crushing Kuo between the two vehicles. Kuo was transported to a medical center and died later that day.
Kuo’s family members and estate filed a complaint against DUSD asserting negligence and premises liability causes of action. The complaint alleged that DUSD was negligent by failing to implement basic safety protocols at the event, failing to communicate safety protocols to volunteers and others, and failing to train and/or supervise employees who were organizing and coordinating the event. It also alleged that DUSD had created a dangerous condition of public property by failing to implement such safety protocols.
DUSD moved for summary judgment, arguing that Labor Code section 3364.5 barred plaintiffs’ claims. Section 3364.5 is part of the Workers’ Compensation Act (§ 3201 et seq.). It provides that “a volunteer, unsalaried person authorized by the governing board of a school district or the county superintendent of schools to perform volunteer services for the school district or the county superintendent shall, upon the adoption of a resolution of the governing board of the school district or the county board of education so declaring, be deemed an employee of the district or the county superintendent for the purposes of this division and shall be entitled to the workmen’s compensation benefits provided by this division for any injury sustained by him while engaged in the performance of any service under the direction and control of the governing board of the school district or the county superintendent.” (§ 3364.5.)
In support of its motion, DUSD submitted Resolution 2011/12-30 (Resolution) passed and adopted by its board of trustees in 2012. DUSD also submitted the memorandum of coverage from the Protected Insurance Program for Schools applicable to the time period of the March 24, 2021 incident.
The trial court granted DUSD’s motion for summary judgment. It determined that death “falls into the category of an injury according to its plain meaning.” And while finding no ambiguity in the term, the court noted that the legislative history of the statute - evidencing an intent to provide school volunteers with the same protection as employees - supported this reading. The court concluded that section 3364.5 defeated its jurisdiction. Judgment was entered in favor of DUSD and against plaintiffs.
The Court of Appeal affirmed the summary judgment in the published case of Kuo v. Dublin Unified School Dist - A169912 (March 2025).
This appeal presented two questions of statutory interpretation: whether the term “any injury” covers fatal injuries like the one Kuo sustained here, and whether DUSD volunteers were “deemed” employees under section 3364.5.
The Court of Appeal wrote "Section 3364.5 provides entitlement to workers’ compensation for “any injury” sustained by a school volunteer while engaged in the performance of service. We conclude that fatal injuries unambiguously fall into the category of “any injury” according to its plain meaning."
Plaintiffs argue that DUSD volunteers were not “deemed” employees under section 3364.5 for two reasons: (1) DUSD’s Resolution did not use the term “deemed,” and (2) DUSD did not treat its volunteers as employees. The Court of Appeal wrote "Neither is persuasive."
"Nothing in the statute supports plaintiffs’ position that a resolution must explicitly use the word “deemed” to trigger section 3364.5. Section 3364.5 requires only that the governing board adopt a resolution “so declaring.” DUSD did exactly that, adopting a resolution stating, “in accordance with Section 3364.5 of the Labor Code, volunteers shall be entitled to Workers’ Compensation benefits for any injury sustained by him/her while in the performance of any service under the direction and control of the District Superintendent.” We do not read into the statute any additional requirement to use magic words, as such an interpretation would defy section 3202’s command that the WCA be liberally construed." - Three Face Charges for Fraudulent LA Wildfire Benefit Claimson March 13, 2025 at 2:41 PM
Three defendants have been charged in recent days with fraudulently seeking federal disaster relief funds by falsely claiming their properties were damaged by the Eaton and Palisades wildfires when in fact they did not have an interest in the affected property or the property was not affected by either fire, the Justice Department announced today. The three defendants – two in Southern California and one in Texas – were arrested this week after being charged with defrauding the Federal Emergency Management Agency.
The allegedly false claims were made in the wake of the Eaton and Palisades fires that started on January 7. Together, the wildfires burned nearly 60,000 acres, destroyed more than 16,000 structures, and resulted in the deaths of 29 people. As a result, the President approved a Major Disaster Declaration, which prompted FEMA to develop a program to provide financial assistance to fire victims.
FEMA offered various forms of relief, a one-time payment of $750, up to $43,600 for “other needs” assistance, and housing assistance for up to 18 months. Homeowners are also potentially eligible for additional relief of up to $43,600 for home repair.
The fraud alleged in the three cases include payment of “other needs assistance” based on false claims of damage to personal property, lost vehicles, and medical and relocation expenses.
Joyce Turner, 55, of Rosharon, Texas, was arrested Tuesday after being charged Friday in a criminal complaint with fraud in connection with major disaster or emergency benefits.
Turner allegedly submitted an application claiming her home had been destroyed in the Eaton fire, but she appears never to have lived in California and in fact had no connection to the address she claimed was destroyed in the fire. Instead, she allegedly forged a lease making it look like she lived there, and she received more than $25,000 from FEMA because of the fraudulent submissions.
“Turner submitted at least ten other applications to FEMA for disaster relief (so eleven total) related to seven other federally declared disasters, e.g., Hurricane Katrina (2005), Hurricane Ike (2008), Hurricane Isaac (2012), Hurricane Harvey (2017), and Hurricane Beryl (2024), and otherwise has a criminal history showing previous arrests and convictions for fraud offenses,” the affidavit states.
Turner is scheduled to make her initial appearance today in United States District Court in the Southern District of Texas and is expected to appear in the Central District of California in the coming weeks.
Tyrone D. Barnes Jr., 38, of Paramount, was arrested Tuesday after being named in an indictment charging him with making false claims that was returned by a federal grand jury on February 21. The indictment alleges that Barnes submitted a disaster relief claim to FEMA for an Altadena property owned by other individuals who did not know Barnes. The true owners of the property contacted FEMA about potential assistance, which is when they learned another person had already submitted an application in relation to their property.
Barnes is expected to make his initial appearance this afternoon in United States District Court in downtown Los Angeles.
Hedeshia Robertson, 36, of Lakewood, was arrested on Tuesday after being charged in a criminal complaint filed Monday. Robertson allegedly filed a fraudulent application for FEMA benefits on January 28, seeking benefits related to a damaged residence in the Pacific Palisades that she did not own, did not rent, and in which she did not reside or work. As a result of her fraudulent application, Robertson obtained approximately $24,899 in FEMA benefits to which she was not entitled. At the time of her arrest, Robertson also allegedly attempted to obtain additional FEMA benefits for a purported property lease in San Francisco. She is due to make an initial appearance in court this afternoon.
The charge of fraud in connection with major disaster or emergency benefits carries a statutory maximum sentence of 30 years in federal prison. The charge of false, fictitious, or fraudulent claim against the United States carries a statutory maximum sentence of five years in federal prison. - SafeLite Resolves IFPA Auto Insurance Fraud Case for $31Mon March 12, 2025 at 2:55 PM
The California Insurance Fraud Prevention Act (IFPA) is designed to protect both consumers and the integrity of the insurance industry within the state. Its primary goal is to combat and prevent fraudulent activities that exploit insurance systems, ensuring that trust and fairness remain central to these services.
What helps make the IFPA effective are its whistleblower provisions. Individuals who uncover fraudulent activities have the opportunity to file litigation against violators and receive a share of recovered funds as a reward for their courage.
An recent IFPA case filed in California involved serious allegations of unethical billing practices by Safelite Group Inc., Safelite Fulfillment inc., dba Safelite AutoGlass, a leading company in auto glass repair and replacement. A former employee, Brian Williams, stepped forward as a whistleblower, filing insurance fraud lawsuits in California and Illinois. He was last employed by Safelite as aproduct development and strategy manager
The Illinois Insurance Claims Fraud Prevention Act (IICFPA) was also central to the Safelite case. This Illinois law also allows whistleblowers to file lawsuits on behalf of the state against entities suspected of submitting false claims to insurers.
According to the allegations contained in Williams' Second Amended Complaint filed in the San Mateo Superior Court last July, to recover damages and civil penalties on behalf of the People of the State of California, arising from an alleged insurance fraud scheme planned and carried out by Safelite.
According to Williams, Safelite consistently billed insurance companies for high-quality OEM (Original Equipment Manufacturer) parts - components trusted for their durability and performance. However instead of using these premium parts, Williams alleged Safelite often replaced them with cheaper, generic alternatives known as "universal molding." Moldings are a rubber or plastic trim, most commonly black in color, that usually run along either the top or the top and sides of, and at times even around, the glass of a vehicle. Molding provides insulation and noise reduction while holding the window in place securely and safely.
The complaint contained examples of invoices sent to Safeco, Farmers and State Farm Insurance, charging for a higher grade molding than the universal moulding. And went on to allege that from "at least 2015 through 2020, Safelite engaged in this practice of using universal molding but charged insurance companies and others for part-specific molding on over 1 million vehicles. In 2019 and 2020 alone, Safelite charged insurance companies and others for part-specific molding, but used universal molding to outfit the vehicles, for over 255,000 vehicles, over 13,850 of which were for vehicles whose glass was replaced in California."
"Safelite AutoGlass was systematically billing for OEM or aftermarket parts when universal moldings were actually used in their place. Furthermore, the data showed that this sort of billing was happening across all insurance clients and customers billed via account, including government agencies, commercial accounts, and fleet accounts."
Another alleged scheme involved additional charges imposed by Safelite during the COVID-19 pandemic. Customers were reportedly billed for cleaning services intended to ensure safety and hygiene. However, the lawsuits alleged that these services were inconsistently applied and offered to only a small fraction of customers, raising questions about the company’s billing practices.
According to news sources SafeLite has agreed to a $31 million settlement to resolve the claims. Safelite did not admit to any wrongdoing. - ER Physician Staffing Firms Face Financial Difficulty & Bankruptcyon March 12, 2025 at 2:54 PM
NES Health, a physician-led staffing firm, is headquartered in Tiburon, California. They specialize in providing physician staffing and healthcare management services, focusing on areas like emergency medicine, hospital medicine, post-acute care, and telemedicine. Their mission has been to support hospitals with tailored solutions to improve patient care, operational efficiency, and overall healthcare delivery.
NES Health was founded by Dr. Allan Rappaport, initially focusing on emergency medicine. Over the years, it expanded its scope to include hospital medicine, post-acute care, and telemedicine. The company prided itself on being physician-owned and physician-led, emphasizing a commitment to quality care and operational efficiency.
In California, NES Health worked with hospitals like Seton Medical Center in Daly City and Sierra View Medical Center in Porterville where they staffed emergency department physicians.
However, financial difficulties in late 2024 led to unpaid wages for physicians at several hospitals, including Seton Medical Center hat ultimately led to its Chapter 7 bankruptcy filing last month. Here are the key challenges they encountered:
- - Cash Flow Issues: The company ran out of available cash and funding, which left them unable to pay their physicians, vendors, and contractors. This included unpaid wages for emergency department physicians at multiple hospitals.
- - Malpractice Coverage Lapse: NES Health could not afford to maintain malpractice tail coverage for its physicians, which is a critical safety net for healthcare providers.
- - Delayed Payments: Physicians and staff experienced delays in receiving their payments, with some going unpaid for up to 2.5 months. This created uncertainty and financial strain for the workforce. - - High - - Liabilities: The company reported liabilities ranging from $10 million to $50 million, far exceeding its estimated assets of $1 million to $10 million.
- - Operational Shutdown: In November 2024, NES Health announced its decision to wind down operations and cease doing business, citing the inability to sustain its financial obligations.
These challenges were compounded by broader industry trends.Several physician staffing companies have faced financial difficulties in recent years, including those operating in California. Here are some notable examples:
- - TeamHealth: This national staffing company has faced lawsuits and financial challenges related to billing practices and disputes with insurers. While they continue to operate, these issues have strained their financial stability.
- - Envision Healthcare: Another major player in the staffing industry, Envision Healthcare, has struggled with debt and operational challenges. They filed for Chapter 11 bankruptcy in 2023, citing financial pressures from declining reimbursements and increased operational costs.
- - American Physician Partners: This company ceased operations in 2023 due to financial difficulties, leaving many hospitals scrambling to find replacement staffing solutions.
These challenges reflect broader trends in the healthcare staffing industry, including rising operational costs, reimbursement pressures, and the impact of regulatory changes. - Court of Appeal Allows Case Against DHS for Underground Regson March 11, 2025 at 5:19 PM
Plaintiff California Healthcare & Rehabilitation Center and more than 20 similar California based skilled nursing facilities operate subacute units. Subacute units provide services to patients requiring less intensive services than those provided in an acute care hospital but more intensive than those provided to general patients in skilled nursing facilities. In addition to the general subacute services provided, plaintiffs also provide ancillary services including physical therapy, speech therapy, occupational therapy, and certain medical supplies.
Plaintiffs participate in Medicare and Medi-Cal programs and have received payments from both. Under California Code of regulations, title 22, sections 51005 and 50761, Medi-Cal is mandated to be the payor of last resort, meaning a facility has to seek reimbursement from other coverage, including Medicare, before seeking reimbursement from Medi-Cal.
“Medi-Cal has a different payment process than Medicare does. Medi-Cal generally pays an all-inclusive, facility-specific, per-diem rate to [skilled nursing facilities]. The per-diem rates are calculated based on actual costs that the facility reported to the Department. Medicare, on the other hand, pays facilities on a per-item basis. If [a skilled nursing facility] patient has both Medi-Cal and Medicare, and Medi-Cal makes a payment on a per-diem basis and Medicare makes a payment on a per-item basis, there may be double payment for the same ancillary services.
Plaintiffs filed a petition for traditional writ of mandate pursuant to Code of Civil Procedure section 1085 and a complaint for declaratory relief pursuant to section 1060, alleging the State Department of Health Care Services and Michelle Baass (in her capacity as Director of DHS) violated a ministerial duty and adopted a regulation in violation of the Administrative Procedure Act (Gov. Code, § 11340 et seq.) by utilizing an overpayment formula based on the amount Medicare paid plaintiffs for ancillary services instead of on the amount Medi-Cal overpaid for those services.
The trial court sustained the Department’s demurrer without leave to amend, finding plaintiffs’ claim was not cognizable in a traditional writ of mandate proceeding and, alternatively, that plaintiffs failed to state a claim the Department violated a ministerial duty or adopted an underground regulation. Separately, the trial court denied plaintiffs’ motion to compel discovery of various documents the Department utilizes while training its employees because it found the documents were privileged.
The Court of Appeal reversed the judgment of dismissal and affirmed the trial court’s order denying plaintiffs’ motion to compel in the published case of Cal. Healthcare & Rehabilitation Center v. Baass - C098043 (March 2025).
Plaintiffs’ petition alleges the Department uses an overpayment formula it adopted contrary to law and in contravention of its ministerial duties and requests a declaration stating so, as well as an injunction against the Department from utilizing the overpayment formula in the future.
State agencies must adopt regulations following the procedures established in the Administrative Procedure Act. These procedures, among other things, require state agencies to provide the public with notice of proposed regulations (Gov. Code, §§ 11346.4, 11346.5), give interested parties an opportunity to comment on proposed regulations (Gov. Code, § 11346.8), and respond in writing to submitted written comments (Gov. Code, §§ 11346.8, 11346.9). Regulations wrongly adopted outside these procedures are known as underground regulations and are void. (Tidewater Marine Western, Inc. v. Bradshaw (1996) 14 Cal.4th 557, 572-573 (Tidewater); see Cal. Code Regs., tit. 1, § 250, subd. (a)(1).)
Determining whether the Department’s purported overpayment formula is lawful and complies with its ministerial duties is an issue reserved for traditional writ of mandate proceedings that review the propriety of quasi-legislative acts and ministerial determinations. (See California Water Impact Network v. Newhall County Water Dist. (2008) 161 Cal.App.4th 1464 at p. 1483.) Accordingly, plaintiffs’ petition is cognizable under section 1085.
Plaintiffs argue the petition sufficiently provides they did not need to exhaust their administrative remedies, as well as states a claim under sections 1085 and 1060 because the Department’s use of the overpayment formula violated a ministerial duty and constituted an underground regulation.
The Court of Appeal agreed that plaintiffs had no administrative remedies to exhaust and that they stated a claim the overpayment formula constitutes an underground regulation. - Physician & SoCal Pharmaceutical Company VP Pleads Guiltyon March 11, 2025 at 5:19 PM
George Demos, then-vice president at San Diego-based Acadia Pharmaceuticals Inc., pleaded guilty in federal court to illegally selling 60,000 company shares, thus avoiding a $1.3 million loss by acting on insider knowledge about the labeling process for a prescription drug with the Food and Drug Administration (FDA).
Demos, a medical doctor who was the Vice President of Drug Safety and Pharmacovigilance and member of the drug label team at publicly-traded Acadia, admitted that he was able to avoid the loss by dumping his shares just two hours before negative news about the labeling process became public.
Through his positions, Demos had access to material information belonging to Acadia, including the drug approval and labeling process with the FDA, before the information was released to the investing public. As an employee of Acadia, Demos was subject to an insider trading policy that prohibited trading in company stock on the basis of material nonpublic information.
As of 2021, Acadia’s only fully FDA-approved pharmaceutical product was Pimavanserin, sold under the brand name Nuplazid, for the treatment of Parkinson’s disease psychosis. Demos admitted that in 2020, he learned inside information that Acadia had applied for FDA approval for the expansion of the label for Nuplazid to treat dementia-related psychosis. Expanding the label was expected to generate significant revenue for Acadia because it would allow the drug to treat a larger patient population.
Demos also admitted, however, that in March 2021, he learned additional inside information that discussions with the FDA had stalled, indicating a problem with the label. Acting on that inside information, Demos sold more than 60,000 shares of Acadia for $2,833,856.15 - less than two hours before Acadia issued a press release announcing deficiencies in its drug application with the FDA, preventing labeling discussions. Demos admitted that based on the inside information, he sold his Acadia stock for $46.61 per share, avoiding the 45 percent drop in stock price, to $25.02, that occurred the next day after the press release was issued to the public. Through this illegal trading, Demos avoided a loss of $1,313,263.
As part of his plea, Demos agreed to forfeit $1,313,263 – the loss he avoided through his insider trading. Demos is scheduled to be sentenced on May 30, 2025, at 9 a.m. before U.S. District Judge Robert Huie.This case is being prosecuted by Assistant U.S. Attorney Janaki G. Chopra. - Cooperation & Assistance of Insured Clause Defends $9M Verdicton March 10, 2025 at 1:26 PM
On January 13, 2017, an automobile accident occurred between Dennis Perez, who was insured by Farmers Direct Property and Casualty Insurance Company and Victor Montez. Charged for driving under the influence and causing bodily injury to another Perez pleaded nolo contendere and served two years in jail. The Montezes alleged Perez’s “legal intoxication” caused the accident and the resulting “severe injuries” to Victor Montez, but Perez claimed that he unexpectedly hit a puddle, causing his vehicle to hydroplane into oncoming traffic.
On March 10, 2017, Victor Montez sent Farmers Direct a handwritten settlement demand letter, to indicate that he sought to settle for the full Policy amount, inquire whether Perez was “doing anything or going anywhere for his job” at the time of the accident, and determine if Perez had “any other insurance policies . . . .” As of May 18, 2017, Farmers Direct told the Montezes that it could not reach Perez “to obtain an affidavit of no other insurance . . . .” However it did offer to settle for the $25,000 policy limit.
Nearly a year later, the Montezes filed their underlying tort action against Perez in state court on May 10, 2018. Farmers Direct appointed counsel to defend Perez in the lawsuit. Perez’s appointed counsel subsequently asserted several defenses, but Perez was uncooperative with his own defense by failing to communicate with his counsel, who eventually retained a private investigator to locate Perez.
On June 15, 2021, the state court allowed Farmers Direct to intervene on behalf of Perez in the underlying tort action after previously denying its request. Farmers Direct incurred over $100,000 in defense fees, to intervene on behalf of Perez ahead of trial in the underlying tort action.
On November 9, 2021, Farmers Direct filed its declaratory judgment action in the federal district court, seeking a declaration that Perez breached the Policy’s provision relating to duties after loss (“Cooperation Clause”), and, in turn, that Farmers Direct no longer has a duty to defend or indemnify Perez in the underlying tort action.
On February 23, 2022, the federal district court entered Judgment, declaring that Farmers Direct: owes no continuing duty to defend and owes no duty to indemnify Perez in connection with the underlying [tort] action . . . because Perez’s breach of the Policy’s Cooperation Clause excuses further performance by Farmers Direct.
During trial of the underlying tort action in state court, Farmers Direct was not able to effectively raise liability defenses, including the theory that Perez hydroplaned after hitting a puddle, because of Perez’s lack of cooperation. On July 28, 2023, the state court entered a tort judgment against Perez of $8,862,730.00 in damages, $881,014.41 in costs and fees, and $3,205,151.67 in prejudgment interest were entered against Perez on November 9, 2023. On August 23, 2023, Farmers Direct paid the $25,000 Policy limit in partial satisfaction of the judgment.
On September 1, 2023, the Montezes filed a motion in Farmers Direct’s declaratory judgment action in federal court to intervene and to vacate the Judgment finding Farmers Direct owes no duty to indemnify Perez on several grounds, including that the Judgment “is void because the [district] [c]ourt lacked subject matter jurisdiction.” The district court agreed with the Montezes in its October 6, 2023 Order vacating the Judgment for lack of subject matter jurisdiction because the amount in controversy was the Policy’s $25,000 face amount, which was less than the over $75,000 statutory minimum.
The 9th Circuit Court of Appeals reversed in the published case of Farmers Direct Property and Casualty Insurance Company v Montez - 23-3320 (March 2025) The 9th Circuit held that the district court erred when it decided that the value of the declaratory judgment action.
In its federal Complaint for Declarative relief Farmers Direct alleged that the Montezes, as the “underlying plaintiffs now contend they are entitled to hundreds of millions of dollars in damages and further contend that Farmers Direct is liable for such damages notwithstanding its Policy limits.” The Montezes’ state court demand served as the basis for Farmers Direct’s claim that the amount-in-controversy requirement was satisfied in federal court, and a federal plaintiff’s “claim in excess of the requisite amount, made in good faith in the complaint, satisfies the jurisdictional requirement.”
The Montezes concede that in their underlying tort action against Perez they “alleged they were seeking for hundreds of millions in damages.” The Montezes cannot now dispute Farmers Direct’s “assumption that the value of . . . their underlying tort claims against” Perez was greater than $75,000, given that they once sought hundreds of millions in damages.
"The judgment was not void because there was at least an “arguable basis” that the amount in controversy was satisfied by considering either the potential excess liability of the underlying tort claim or Farmer Direct’s anticipated future defense fees and costs, or both." - Failure to Oppose Summary Judgment is Good Cause to Grant iton March 10, 2025 at 1:26 PM
Melissa Mandell-Brown filed a complaint against her employer Novo Nordisk, Inc. asserting 16 causes of action, including statutory claims for discrimination, sexual harassment, and retaliation under FEHA and the Labor Code and common law claims for breach of contract, wrongful termination, and intentional infliction of emotional distress.
On May 18, 2022, defendants filed their motion for summary judgment or, in the alternative, summary adjudication and argued that none of plaintiff’s causes of action survived summary judgment. The supporting separate statement included 161 undisputed facts. Defendants also submitted an attorney declaration authenticating 25 discovery exhibits and six witness declarations authenticating another 51 exhibits and containing detailed explanations of the non-discriminatory and non-retaliatory reasons for the elimination of plaintiff’s job position. The notice of motion set the hearing date for August 3, 2022, with a trial date then pending for October 4, 2022.
Two days before the hearing on the motion, on August 1, 2022, plaintiff, who had not filed an opposition to the motion, applied ex parte to continue the hearing. The trial court granted the application, setting the hearing for September 16, 2022, and continuing the trial date to November 8, 2022.
On September 14, 2022, plaintiff, who still had not filed her opposition, again applied ex parte to continue the hearing, and the trial court granted the application, setting the continued date for October 14, 2022, and continuing the trial until December 6, 2022. At the October 14, 2022, continued hearing on the motion, plaintiff did not file an opposition or separate statement, request a third continuance, or appear at the hearing. The trial court denied the third continuance. And it also issued a minute order granting defendants’ motion for summary judgment based upon no opposition, "plaintiff is conceding that the motion should be granted."
The Court of Appeal affirmed the judgment for defendant in the published case of Mandell-Brown v. Novo Nordisk Inc. et al. - B326147 (March 2025)
The requirements for opposing a motion for summary judgment or adjudication are set forth in CCP section 437c, subdivision (b)(3), which provides that: “The opposition papers shall include a separate statement that responds to each of the material facts contended by the moving party to be undisputed, indicating if the opposing party agrees or disagrees that those facts are undisputed. The statement also shall set forth plainly and concisely any other material facts the opposing party contends are disputed. Each material fact contended by the opposing party to be disputed shall be followed by a reference to the supporting evidence. Failure to comply with this requirement of a separate statement may constitute a sufficient ground, in the court’s discretion, for granting the motion.”
Separate statements are “required, not discretionary, on the part of each party, and the statutory language makes the failure to comply with this requirement sufficient grounds to grant the motion.” (Whitehead v. Habig (2008) 163 Cal.App.4th 896, 902.)
Further, the trial court here granted plaintiff two continuances to file her opposition, which required two continuances of the trial date. Notwithstanding the additional time the court afforded her to file opposition papers, plaintiff failed to submit points and authorities addressing defendants’ evidence as it related to the elements of her claims, any declarations presenting disputed factual issues, or a separate statement to assist the court in parsing which of the 161 facts asserted and supported by defendants’ evidence she disputed.
"Under these circumstances, we conclude the trial court did not abuse its discretion in granting the motion pursuant to section 437c, subdivision (b)(3)." - Proposed Law Mandates Healthcare Insurance Denial Rate Reportingon March 6, 2025 at 11:53 AM
Health insurer claim denial rates have been a significant concern in recent years. In 2024, Experian Health reported that 38% of healthcare providers experienced claim denials for at least one in ten claims, with some organizations seeing denial rates of more than 15%. The denial rates for insurers of qualified health plans (QHPs) sold on HealthCare.govwere also notable, with 19% of in-network claims and 37% of out-of-network claims being denied, resulting in an average denial rate of 20% for all claims.
The variation in denial rates among insurers is substantial. For instance, UnitedHealthcare denied nearly one-third of claims, making it the company with the highest denial rate among those offering plans on Affordable Care Act exchanges. Common reasons for claim denials include missing or inaccurate data, lack of prior authorization, and excluded services.
Despite the high denial rates, consumers rarely appeal denied claims. In fact, fewer than 1% of denied claims were appealed, and insurers upheld 56% of those appeals. These statistics highlight the ongoing challenges faced by healthcare providers and patients in dealing with claim denials.
The government has taken several steps to address the issue of health insurer claim denial rates. Here are some key actions:
- - Transparency Requirements: The Affordable Care Act (ACA) mandates that insurers report transparency data for all non-grandfathered health plans sold on and off the Marketplace, including fully-insured and self-insured employer group health plans. This data is available to federal and state insurance regulators and the public.
- - Data Analysis and Reporting: The Centers for Medicare and Medicaid Services (CMS) analyze and release data on claims denials and appeals for non-group qualified health plans (QHPs) offered on HealthCare.gov.This data helps identify patterns and areas for improvement.
- - Policy Recommendations: The ERISA Advisory Council (EAC), a body appointed by the Secretary of Labor, has made 12 policy recommendations to improve the claims denial and appeals process. These recommendations aim to address dubious denial processes and make the appeals process less difficult for consumers.
- - Consumer Protection: The government continues to monitor and enforce regulations to protect consumers from unfair claim denials. This includes ensuring that insurers comply with transparency requirements and addressing any violations.
And now in California Assembly Bill 682, proposed new legislation authored and introduced by Assemblymember Liz Ortega of Hayward, would mandate public reporting on the denials of insurance claims for California’s patients.
The new bill seeks to mandate collection and public reporting of health insurance claims denial information for each health plan regulated by the California Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI).
The information collected and reported would include the number of claims denied, the costs of denied claims, whether or not artificial intelligence was used in the decision, and — significantly — reasoning for denying claims, such as a lack of prior authorization or an out-of-network provider.
California Nurses Association (CNA) and its more than 100,000 members across California today shared their support for Assembly Bill 682 in its press release. - Ortho Surgeon Inflation Adjust Pay Over 20 Years Declined 38%on March 6, 2025 at 11:53 AM
Healthcare finance in the United States is continually changing with increased consolidation of healthcare organizations, fluctuating reimbursement cycles, and shifting institutional and federal policy. The economics of practicing medicine are dynamic and challenging relative to other professions.
The purpose of new a study just published in the Journal of Arthroplasty (Pereira DE, et al. J Arthroplasty. 2025;doi:10.1016/j.arth.2025.02.012) was to analyze compensation trends in orthopaedic surgery over the past 20 years compared to other professions.
To accomplish this purpose the authors reviewed income data for orthopaedic surgeons and other professions every five years from 2000 to 2020 which was collected from the United States Bureau of Labor Statistics and peer-reviewed literature. Income data were adjusted for inflation and analyzed to identify trends in compensation.
The analysis showed that the rate of absolute income trajectory over two decades for orthopaedic surgeons when adjusted for inflation was -38%. Outside of healthcare professions, economists, lawyers, and engineers saw some of the highest increases with inflation-adjusted increases at +31, 26, 24%, respectively. Orthopaedic surgeon salary rates declined the most of all professions analyzed, including all healthcare workers.
As a result of this analysis, the authors concluded that the adjusted orthopaedic surgeon compensation has declined significantly in the two decades between 2000 to 2020. Compared to other high-skilled professions, orthopaedic compensation showed the greatest decline in adjusted rates over time.
Thus they concluded that "This trend carries major implications for the future of the field, potentially affecting recruitment, satisfaction, burnout, and patient access to care. It underscores the need for a re-evaluation of compensation models in orthopaedic surgery to ensure sustainability."
They also noted that inflation, rising interest rates, staff shortages, policy changes, decreases in per-case reimbursement, financial burdens of Medicare and Medicaid patients, as well as increasing year-over-year expenses, may play a role in compensation decreases for orthopedic surgeons.