Van Ness v. Blue Cross of California

In 1991 appellant Richard Van Ness purchased health insurance from respondent Blue Cross of California under its prudent buyer program. That program established a two-tiered benefit schedule—the negotiated fee schedule for participating providers and the limited fee schedule for nonparticipating providers. Benefits under the negotiated fee schedule were greater because network providers agreed to cap their fees for Blue Cross subscribers. Van Ness’s treating physician was not part of the prudent buyer network.

When the benefits Blue Cross paid for colonoscopy surgery amounted to just over one-third of his doctor’s actual fee, Van Ness sued Blue Cross asserting multiple causes of action. He lost on summary judgment. We conclude that the Blue Cross policy and promotional materials were not ambiguous and did not support an objectively reasonable expectation that the insurer would pay enhanced benefits beyond those available under the limited fee schedule; nor did the limited fee schedule amount to an exclusion from coverage. Thus there is no legally cognizable basis to afford Van Ness relief. Accordingly, we affirm the judgment.

I. Factual Background

A. Development of…