Coast Plaza Doctors Hospital v. UHP HEALTHCARE

The issue in this case is whether a health care provider has a right to se.ek reimbursement directly from the health care insurer for services rendered to enrollees of the health care plan. Its resolution depends in part on whether, under the Knox-Keene Health Care Service Plan Act of 1975 (Health & Saf. Code, § 1340 et seq., Knox-Keene Act) an insurer has a direct obligation to reimburse the provider. In the published portion of this opinion we conclude that the Knox-Keene Act does not apply to the factual circumstances here, and does not bar the provider from seeking direct compensation on a common law breach of contract theory or under the unfair competition law (Bus. & Prof. Code, § 17200).

In the unpublished portion of the opinion we conclude the trial court erred in sustaining a demurrer as to the cause of action for breach of contract by assignment, but correctly sustained the demurrer without leave to amend to the causes of action for breach of implied contract, breach of contract based on third party beneficiary theory, open book account, quantum meruit, and unjust enrichment. Because we conclude that the Knox-Keene Act does not apply to this case, we do not…