2 ".l 4 5 1 8 Q BINDING ARBITRATION ADR SERVICES, INC. 10 II 12 13 \ 'S. 14 15 Claimant. ~ Arbitration No. II 013 ARBITRATOR s A WARD 16 I 7 Respondents. 18 19 ~0 21..,.. --'.,. _) ---.... _ --- _. ; Claimant individually and successor in interest to. complaint assens claims for (I) medical malpractice/ professional negligence: (::?) breach of contract: (3) breach of the covenant good faith and fair dealing and violation of Insurance Code section 790.3: (4) negligent and statutury violation of Civil Code section 34:!8: and (5J unfair business practices in violation of Business and Professions Code section 17200 against respondents. and Dr. (''Dr. :!6 l <colkcti\'ely. "Respondents.. ). :!7 Regarding the first cause nt' action... The dements of a cause of action tor negligence are ~8 wdl established. They arc '(a) a kgal duty tu use due can:; (b) a breach of such legal dut~; land] A rhi1r.11inn 1\n II 011 - --- --
(c) the breach as the proximate or legal cause of the resulting injury. (!.add\'. ( 'mmr.1 (~(.\'an 'l.\.fmeo ( 1996) 12 Cal.4th 913. 917.) Medical negligence is still negligence. ''With resj'>'!ctto 3 professionals. their specialized education and training do not serve to impose an incrc<~scd duty 4 of care but rather are considered additional circumstances relevant to an overall assessment of 5 what constitutes ordinary prudence in a punicular situation. Thus. the standard for 6 professionals is aniculated in temls of exercising 'the knowledge. skill and care ordinarily 7 possessed and employed by memhc!rs of the profession in good standing....' ICitation.j" 8 (F/ouwl,.. Tummn:.\1emorial Ho:;pital.\fediml Centa (1994) 8 Cal.-4th 99~. 9q7-998: sc:c 9..-I so C 1\('1. No. SOO.) 10.. Becaus~ th~ standard of car~ in u m~dical malpractice case is a matter pe-culiarly within I 1 the knowledge of cxpcns [citation]. cxpen testimony is requirl!d to pro\'e or dispro\'e that the 12 defendant performed in accordance with the standard prevailing of care unless the negligence is 13 Ob\'ious to a layperson. (Citation.)" c.johnson 1'. Superior Court ( 2006) 143 Cal.App..tth 297. 14 305.).. In a medical malpractice action. a plaintiff must pro\'c the dct~ndant' s negligence was a 15 cause-in-fact ofinjury.[citntion.j'thc law is well settled that in a personal in.iury action 16 causation must be proven within a reasonable medical probability based I on! competent cxpcn 17 testimony... (Citation. j" (Jenning.'>,.. Palomar Pomt rcldo 1/.:alth Sy... tems. Inc. t ~00-4) I I 4 18 Cai.Apf'.4th 1 HUt I I 17. l I 9 Claimant argued R~spondems brc:achc:d the: standard of care in several ways. On th~ 10 issues of breach and causation. the arbitrator tinds claimant did not establish either of these 2 I elements by a preponderance: of the evidence. Whether or not decedent was pro\'ided with a 22 current asthma actiun plan. the arbitr.ttor concurs with thc Respondents' ex pen that the lack of a 23 current asthma action plan did nor. within a reasonable medical probability. result in 24 death. Similarly. the arbitr.ttor agrees with Respondents' expert that the fitilure to 25 prescribe Prednisone at the home and the failure to conduct furthl.!r asscssmc:nts did not. within a 26 reasonable medical probability. result in death. Claimant did not carry 27 her burden of establishing. that Respondents breached the standard of care in Jailing to prescribe 28 an additional inhaler/ refill. I 'l \rnimuinn ""o 110 I 1
Regarding claimants' second and third causes of action. "A statement of a cause of action 2 for bn:ach of contract r~u i res a pleading of Cl) the contract. (2) plaintio~s perfonnance or 3 excuse fornon perfonnance. (3) defendant's breach. and (4 ) damage to plaintiitthercfrom. 4 (.'krmstic.\. lm.,.. Treptt' Constrm:t ion Co.. Inc. { I t>71 ) 14 Cai.App.3d ~87. Q 13.) " Every 5 contract imposes upon each pany a duty of good faiih and fair dealing in its pt:rfomlance and its 6 entorccmcnt." (Rcst.:!d Contracts. 205.) "There is an implied covenant of good faith and fair 7 dealing in e\'cry contract that neither pany will do anything which will injure the right of the 8 other to receive the benefits of the agreement." ( Conuuwle \'. 7i'tulc:r., & Cit nc:ral Ins. ( 'o. ( I 958) tj 50 Cal.2d 654.658: sec also CACI. No. 325.) Purely trom a pl~ading r erspcctivc. claimant' s I 0 third cause of action appears to be redund;mt of her second cause of action. "I \V)here breach of 11 an &~ctual h:nn is alh:gcd. a separate implied covenant claim. based on the smnc hrcach. is 1::! superfluous... (Guz,.. Becluel :\'ational. bw (::!CJOO) 24 Cal. 4th J 17. 327.) In any case. claimant 13 did not carry her burden of proof in establishing eith~r one of these: claims. 14 Regarding claimant s founh cause of action. "Civil Code SI!Ction 3 4~8 places real 15 obligations on a health care 5erviec plan." ( Wawnahe '' C 'al~lilmi(t Phy.'>icions.c.. eitict' ( ~OOR) 16 169 Cal.i\pp.4th 56. 66.) Subdivision (a) of Civil Code section 3428 provides: "For sen ices 17 rendered on or after January 1. 2001. a health care service plan or managed care entity... shall I M have a duty of ordinary cure to arrange tor the provision of medically n~cessnry health care 19 service to its subscribers und enrollees. where the health care service is a benefit provided under 20 the plan. and shall be liable for any and all harm lcgallr caused br its failure to exercise that 21 ordinary care when both uf the following apply: t I) The failure to exercise ordinary car~ resulted 22 in the denial. delay. or modilieatiun of thc health care service recommended for. or furnished to. ~3 a subscriber or enrollee. (:!) The subscriber or enrollee sutrered substantial haml... The arbitrator 24 agrees with Respondents that claimant did not c-arry her burden of proof in establishing this 25 claim. Claimant oftcred no evidence in suppon of direct liability against n:sponjents :2(-, 27 Regarding claimant's li fth cause of action for unfair husincss practices. the claim is ::!8 prl!dicated on a showing of Respondents liability on any of thl! lirst four cause:; of action. For.>\rhitrntion Nn 11 01 \ 3
the reasons stated above. claimant did not carry her burden in establishing liability against 2 Respondents on any of the first four causes of action and. therefore. claimant also fails to curry 3 her burden with regard to the fifth cause of action. 4 Consequently. the arbitrator tinds in favor of Respondents on all tive causes of action. 5 Claimant shall recover nothing from Respondcmts. 6 7 8 9 Nothing in this arbitration decision prohibits or restricts the enrollee from discussing or reporting the underlying facts, results, terms and conditions of this deeision to the Department of Managed Health Care. 10 II 12 l3 14 15 16 17 18 19 20 21,,.,...,./ -.;:----1 -::-;t{~.--z- <.J.;;, (:~-<-2~- Hon. James C. Emc:rson (Ret. l 27 28 I Arhirrarion N~ I 1011 -- 4 ------------ -- --. ------ ------
1 2 3 4 5 Attorneys for Res~ondents 6 7 8 9 10 11 12 13 14 15 In The Matter Of The Arbitration Between: and Claimant, Arbitration No.: 11671 ORDER GRANTING RESPONDENTS MOTION FORSUNfldARYJUDGMENT Date: July 12,2013 Time: 10:00 a.m. Location: Telephonic Appearance R:::. e::::'s=o::::n<:.:.le::::n:;:ts:::.: -------------' Arbitration Date: October 21,2013 16 The Motio* for Summary Judgment filed by Respondents 17 18 19 20 21 22 23 24 25 26 27 28 i came on regularly for hearing before The 1-lonomble James R. Emerson (Retired) on July 12,2013.., Esq.. appeared for the respondents, however, claimant I having been duly n,oticed, failed to appear. i No legal 01'1 fnctual opposition was filed by claimant prior to the hearing. The Arbitrator flnds that I the declarations fil$<1 by the respondents are persuasive and sufflcient to carry the motion had the claimant!i appeared and that there exists no triable issue of fact to be adjudicated. Accordingly, good cause exists to grant, and the Arbijrator does hereby grant, the respondents' Motion for Summary Judgment in its entirety. Claimant will take nothing by his claim. Each party shall bear its own attorneys fees and costs. IIIII Ill!/!Ill/ ORDER GRANTING RESPONDENTS MOTION FOR SllMMARY JUDGMENT
l 2 3 7 8! 10 I 111 12 13 14 15 19 20 21 22 23 24 25 I I i 26 I 27 Nothing in this Order prohibits or restricts the enrollee fl"om discussing or reporting the i underlying facts, results, terms and conditions of this Order to the Department of Managed Health I Cam 2 ORDER GRANTING RESPONDENTS MOTION FOR SUMMARY JUDGMENT 28 i 91 I
2 3 4 5 6 7 8 9 10 BINDING ARBITRATION Al)I{ S~:RV I CES, INC. 11 (in h<. r 0~11 capacity. and as Arhitratio11 '.lo. I 0995 12 Successor in I ulcre.sl to lhc EsUllc of Dcccd<. nt 13 ); arll1 /\Rlll'I RATOR'S AWARD 14 Clainlants, 15 16 17 18, tv1.l)., Cl (II., f{espondents. 19 20 Claimants and (co11cctiv<:ly. ' Claimants") assen a clai1n 21 tor professional negligence (1nedicat n1alprac-tice) ag.ain~1 re~pondcnls 22 21 M.ll., an~. M.D. (collc<'tivcly, "Respondents"). 2~ The e.len1enl..:; of a cau~ of actil)ll for negligc::nct: arc vtcll <.'Slab1ishctL Tht y arc (a) a 25 legal duty to use due care.; (b) a breach of.o;.uch legal duly: Lan<.IJ (c) the brc~ch a:; the proximate 26 or Jcgal <.:ttusc of the n sulting i~iut)'. "'(Ladd'' Cou111.. v of.<ian 1\.lutet1 (1 <)96) 11 ( 'aj.41.h 91 J, 27 917.) Mcdi..:al ncgligt.:ncc.~ is ~till ncgligcnoc. ' \Vith rcs1,cct to l'rofes.siojlajs. their SJ'>eCial i1ed 21': education and trainiog d<1 oot 5.erve tc) irnpost! un inc.:rcu.scd duty of c. arc but IJ.thcr arc considc. rcd
additional circunlsta.n<:~s relevant 0 an overall a.::sessn1en1 c..1f '"hc1l 1.:on::tlilolt:~ ordiru1r}' 2 prudcnc-<:' in a panicular situation. Thus. the standard for profi::ssi<)n9i:,. is ar1iculalcd io Lenn:-. or.3 cxc..':fcising 'the kilo\\)edgc. ski11 and care ordinarily J>Ossessed and e1n1llt))ed ll)' nleinher$.ofthe 4 profe:::$.il)ll i 1l gt)l)d 'ltan<ling... : l('i1u1icnl.j.' (t:to... :er~ v Torr<111ce J\f(i1nori<1I Hospil<1/ Jie<li<. <1/ 5 Center (1994) 8 Cal.4th 992. 997 99X: "'"al«> CACI, No. 500.) 6 "Bec.ause the standard of<:are in a nledicaj nlaf1lra~til:t:: 1.:u~ i ~ ~ rnaut::r pt::eulihrl) v.. i1hin 7 lhc.. k.no\vlcdgc Of expcns' rcitation ). exj)c'n testillloll). is required 11) prn\'e t)r di:::pro\, e thal thl! X di::ft:ndant pcrf(.lrme,.xl in ac.. cordunce vi:ilh th<. stru1dard prevailing of car~ unless the negligence is 9 oh\'iou..::: to a la~ 1)c?rson. l<:i1ation.j" (.11>/111.'ion,.. \'u1jerior ('ourl (2006) 143 t~u1.app.4lh 297. I 0 305.) "l n a n1edical rnalpractice actio11. a plain Liff lllusl pro\c tht: dc:lt!ndaru :-. oegl igence- v.a.~ a 11 causc in fit<.'l ofi~jury. rcitation.1 Thc )a\\' is \Vell settled that in a persrinal injury action 12 cau~jl ic.,1n mu~l be proven v. ilhin a rc::i.sonable medical probability based. (onl co1npctcnt cxpc-11 13 te~ti nlony... lc ii..'llicnl.j.. (Jenni11gs,.. /'(J/<nnar Pon1er<1<lo Healrh S)'Ste1ns.!11c. (2004) l 14 14 Cal.App.4th 1108. I I I 7.) 15 As is lypica)1~ the case in mcdica) 1nalprac1ice clainls. llle arbitrator is i'1'c'senlc'd ''ith 16 c~1111peli ng c:xpc:n l t::':'-l i mon~ regarding lhc appropriate standard of c-.are. breach. and causation. 17 The arhitralor. iu hi~ n 1tc ri:; lht: f'~1t.:t llndt:r. dctcmlln<.'s \vhic.. h of the co1npeting experts is the 18 n1orc con\ inc.. ing. ($(.'('general!)' P1. 011lc v..<il.'ato11 (2001 ) 26 ('al.4th 598. 648-.. ihe j ury i:; 19 cap~1blc of deciding \\hic., h of lhc.. competing ex pens is the n1ore convincing... ) 20 "tlie hi" i ~ \Veil sctllcd that in a pc.. rsonal inju~ action causation n1u..'t he pro\. en 21 v. ithin a n.::a..".>uubje mejic~1l probability based on c.on11)etent exj)f'rt testin1ony. 22 ):lere possihilit)' alone i~ i f1:;;uffi~ie11l lfl i::-.;lnbli:;h H prima ta(.'ic.. c..-.asc..-. That th-crt~ is 23 ~1 di~linclion bctv. cen a n~asonablc n1cdic-.al 'j)(1)hahiliry' aod a O)edi~al 2-4 p<:1.s.;ibili1:v needs lilt}c discussion. There c~u1 be n1an: possible causes: indeed 25 an iofinite 1unlhcr- ~)r i.:i r(;utr1'.:l1 i1111.:e~ lbtll can produce an i1tjtu: or disease. :\ 26 possible cause only be-con1es 't)rl)hahle \\ hen, in the absence of other retisonablc 27 causal explanations. it beco1111. s 111or1. lik~~v tl1un J"tol thut the in;ur.v 11 a.\ 11result1if 28
its t1ctit>n. rhis. is 1hc 1)u1cr limi1 1,l f 2 subnlined co dle jury. in1crcn<. c upon \Vhich an issue may be j ' 4 Thus. pro11cring: un cxpcrl opinion that there is so111e theoretical J')()S..~i hility the 5 oegligcnl ;)Ct <:ouki /J(,J\'(' bt!en u cuusc-in-1acl of a pat1icttlar injw) is insufficient 6 LO establish cau~~11ion. Instead, 1bc plain1ilr musl otl<. r an expert opinion that 7 contai11s a rea~)jled explanation illu1t1ioating '"by!he JN<: l~ have convinc<. d the 8 expen, and therefore. should con\o ince. the jury. Lhat it i~ m<1re pr<1huhle 1ht111 not 9 the ncgligcn( acl 'A'as u cuusc-in-(rct of the plaintiil's injury: 10 (.Jennings r. Pu/01nar Po1ner1ulo I lea/th.1:i)'sle1ns. 111<-. (2004) J 14 Cal.App.4th 11 OS. 1117-11 1118: internal citations: and pullcrua1i110 on1i1ted; ertlpluj$i!) original.) 12 In this case. du~ arbitrator finds d1e expen te-5tin1l'jll)' pmffe-red hy ( 1airnalll$. regardi1lg l J causation insufflcicnl to sustai11 their burden of proof. Vlhile it is abundanll)' clear that 1 ~ dc.::alh \l AS trrjgii.: and a 1.ri:cne11dou::. loss for c:taimanls. the evidence do<. s 11ot support a JS finding that it is 01ore prt)hahle than lll)t that fill}' acls <1r vrr1 is~dons l:iy lhc Respondents,.. 'Crc u 16 cause-in-fact of death. /\!though c:laio1ant$i' ex pt:rl~ p('l:;tulated a lhcvry lhat 17 18 19 20 21 22 n1y<.~lopro}ifcrativc disorder (M'PO) caused hinl to ~iffer a fatal suhdural he,natorna, the causal nexus i::. r~1r Loe.> alleoualed 10 :::;uppor1 any liability.. l\cc.ordingl)' the arhitrator find::; in 13.vl"'lr <.)f l{e~pondr.;nt::>. C l~1imanls sh(1ll rt:covcr nothing fron1 Rcs1>0ndent. Nothing in this arbitration d e-.cis ion llrohihits or rcstrii::ts the cnrolltc fro rn.,liscussing or rfporting the underlying facts, rt>.sults, ternt!i: and condition!i: of thi!i: decision to the l>e1lartn1c11t ofl\.1anagt-d llealth ( ~a re. 24 25 Dated:,''e~- '/ 2.cl3 26 -. "..... z~~ -t~.,,.,., ~(c"u1. J arn~ ('. r;men;<,1n (R.:L) 27 28 J A 1hi1ri:.1i 1"1t'I 'J" 1 nooo;