Opinion
Blue Shield of California Life & Hеalth Insurance Company (Blue Shield) seeks a peremptory writ of mandate directing the trial court to reverse its order denying Blue Shield’s motion for summary adjudication of plaintiff and real party in interest Myma Yumiko Kawakita’s tort cause of action for bad faith breach of a health insurance policy she obtained from Blue Shield. Blue Shield contends the cause of action is barred by the two-year limitations period for such claims, and was not extended to three
FACTS AND PROCEDURAL HISTORY
In July 2009, Myma Kawakita sued Blue Shield, stating causes of action for breach of contract and tortious breach of the duty of good faith and fair dealing based on Blue Shield’s August 2006 decision to rescind Kawakita’s health insurance policy shortly after she received approval for, and then underwent, gastric bypass surgery. After her medical providеrs submitted claim forms for the procedure, Blue Shield looked at Kawakita’s medical records and learned that Kawakita’s application for coverage painted an inaccurate picture of her health.
The application said Kawakita was five feet eight inches tall and weighed 140 pounds. It also answered “no” to questions about the existence of certain medical conditions as part of her medical history. In fact, Kawakita was five feet six inches tall and weighed 307 pounds. Her medical records showed the existence of numerous ailments that were not listed оn her application, including hypothyroidism, high cholesterol, insomnia, depression, and obesity, along with a physician’s recommendation that she undergo a psychiatric evaluation and attend weight loss classes. Blue Shield rescinded primarily because of the height and weight discrepancies, but its rescission letter also noted the existence of Kawakita’s various health problems.
Kawakita bought her policy through Blue Shield’s alleged agent Steven M. Stendel, and claimed that Stendel was responsible for the misstatements in her application. She sued Blue Shield for breach of contract, tоrtious breach of the implied covenant of good faith and fair dealing, and declaratory relief.
Blue Shield brought a motion for summary adjudication of the tortious bad faith cause of action, contending it was barred by the two-year statute of limitations for such claims. (Code Civ. Proc., § 339, subd. 1; Love v. Fire Ins. Exchange (1990)
Although sectiоn 10350.11 prescribes the language to be used in a health insurance policy’s provision concerning the time in which to sue on the policy, insurers are permitted to use different language that is not less favorable to an insured. (§ 10350.) Kawakita’s opposition to the motion pointed out key differences between the statutorily required limitations provision and the language actually used by Blue Shield. Under the policy issued to Kawakita, suit for any matters arising out of the policy could be brought within three years of the date when coverage for benefits was denied.
The trial court denied Blue Shield’s summary adjudication motion. According to the trial court, the language in Blue Shield’s limitation provision was “exactly the same” as that in section 10350.11. Because tortious bad faith claims were considered to be actions “on the policy” for purposes of the catchall one-year limitations provision mandated by statute for fire insurance policies (§ 2071), the trial court reasoned that such claims were also on the policy for purposes of health insurance policies under section 10350.11. By parity of reasoning, the trial court found that bad faith tort actions against health insurers must be subject to a three-year limitations period under section 10350.11.
STANDARD OF REVIEW
In addition to moving for summary adjudication, parties may move for summary adjudication of individual causes of action on the ground that they lack merit. (Code Civ. Proc., § 437c, subd. (f)(1).) The rules applicable to summary judgments apply equally to motions for summary adjudication. (Lunardi v. Great-West Life Assurance Co. (1995)
A defendant moving for summary judgment meets its burden of showing that there is no merit to a cause of action if that party has shown that one or more elements of the cause of action cannot be established or that there is a complete defense to that cause of action. (Code Civ. Proc., § 437c, subds. (o)(2), (p)(2).) If the defendant does so, the burden shifts back tо the plaintiff to show that a triable issue of fact exists as to that cause of action or defense. In doing so, the plaintiff cannot rely on the mere allegations or denial of her pleadings, “but, instead, shall set forth the specific facts showing that a triable issue of material fact exists . . . .” (Id., subd. (p)(2).) A triable issue of material fact exists “if, and only if, the evidence would allow a reasonable trier of fact to find the underlying fact in favor of the party opposing the motion in accordance with the applicable standard of proof.” (Aguilar v. Atlantic Richfield Co. (2001)
1. Blue Shield’s Contention That Section 10350.11 Does Not Extend the Limitatiоns Period for Tortious Bad Faith Claims
Health insurance policies are considered a form of disability insurance (§ 106, subd. (b)), and all such policies sold in California must contain certain provisions as set forth in sections 10350.1 through 10350.12.
Relying primarily on federal court decisions, Blue Shield contends that section 10350.11 establishes nothing more than a contractual limitations period keyed to the filing of proofs of loss that has no effect on the statutory two-year limitations period (Code Civ. Proc., § 339, subd. 1) for tortious bad faith claims. Instead, Blue Shield contends it applies to only actions on the policy, which means only claims for breach of contract or for contractual bad faith, not for tortious bad faith.
The first of these decisions is Wetzel, supra,
In Flynn v. Paul Revere Ins. Group (9th Cir. 2001)
An earlier decision by a California appеllate court suggests a similar result. In NN Investors Life, supra,
None of these decisions concerned policy language that deviated from section 10350.11. Assuming for argument’s sake that Blue Shield’s interpretation of section 10350.11 is correct and that inclusion of section 10350.11’s language in a policy does not lengthen the two-year statute of limitations for tortious bad faith claims, as we explain belоw, we conclude that the statutory language does not apply to Blue Shield’s policy.
2. The Limitations Provision Drafted by Blue Shield Applies to Kawakita’s Tortious Bad Faith Claim
As noted earlier, even though health insurance and other disability policies “shall contain” provisions with the wording that appears in section 10350.1 through 10350.12, “the insurer may, at its option, substitute for one or more of such provisions corresponding provisions of different wording approved by the [Insurance] commissioner which are in each instance not less favorable in any respect to the insured or the beneficiary.” (§ 10350.) We concludе that Blue Shield substituted a more favorable contractual limitation
Under the heading “Commencement of Legal Action,” the policy issued to Kawakita provides: “Any suit... to recover . . . damages concerning . . . any other matter arising out of this Plan, may not be brought prior to the expiration of 60 days after written proof of claim has been furnished and must be commenced no later than three years after the date the coverage for benefits in question were first denied. ” (Italics added.)
This is far different from the terms of section 10350.11, which states that no aсtion “to recover on this policy” shall be brought three years “after the time written proof of loss is required to be furnished.” Blue Shield contends that actions on a policy are limited to the payment of benefits under contract law theories.
(3) Had Blue Shield used language that was substantially identical to section 10350.11, the traditional insurance contract interpretation rule that ambiguous policy provisions are construed most favorably to the insured would not have been applicable. Instead, we would use traditional statutory interpretation principles and construe the language in order to implement the intent of the Legislature. Because Blue Shield departed from the statutorily mandated language, we will apply insurance cоntract interpretation principles and construe any ambiguities in a manner that protects the expectations of a reasonable policyholder. (National Auto. & Cas. Inc. Co. v. Underwood (1992)
In determining whether the policy language at issue here includes tort causes of action, we observe that contractual provisions requiring the parties to arbitrate “any dispute or other disagreement arising from or out of’ an agreement, or “any problem or dispute” that arose under or concerned the agreement, have been held to be so broad that they encompass tort as well as contract claims. (EFund Capital Partners v. Pless (2007)
In essence, the policy told Kawakita that any suit for damages for any matter arising out of the plan had to be brought within three years of the
Blue Shield challenges this interpretation on three grounds: (1) because the provision is still tied to filing proofs of claim, and Kawakita never did so, she may not take advantage of the provision; (2) evidence that Blue Shield intended to waive the two-year limitations period for tortious bad faith claims is not in the record; and (3) the phrase “any other matter arising out of this Plan” must be constmed with reference to the more limited class of occurrences listed before it, which are exclusively contract-related claims. We take each in turn.
The first ground is a variant of Blue Shield’s contention that section 10350.11 is nothing more than part of a statutory proof of loss framework for contract claims which are brought on the policy, and therefore does not apply at all to tortious bad faith claims. Under Blue Shield’s policy, when a preferred provider supplies medical treatment, the provider typically files a claim with Blue Shield. The policy states that an insured files a proof of claim when a preferred provider fails to bill Blue Shield, or when the insured receives treatment from a nonpreferred provider. During oral argument, counsel for Blue Shield contended that the policy’s limitation provision did not apply because Kawakita’s providers submitted claims to Blue Shield, meaning that Kawakita herself never filed the proof of claim that was required to trigger the three-yeаr period.
This contention might make sense if we were limited to construing.section 10350.11, and if Blue Shield’s interpretation of that provision were correct. As already discussed, however, Blue Shield’s use of more favorable language has taken this matter outside the realm of statutory interpretation and into that of contract interpretation. Therefore, we construe the policy as a reasonable
Under the heading, “Notice and Proof of Claim,” the policy provides the mechanism by which an insured submits a proof of claim. Blue Shield contends this means that only an insured may do so, and that its limitation provision applies only in that instance. However, under the caption “Your Blue Shield Life Active Start Plan 25 and How to Use It—,” the policy states: “Preferred Providers submit claims for payment after their services have been received. You or your Non-Preferred Providers also submit claims for payment after Services have been received.” (Italics added.) Under the caption “Payment of Benefits,” and the subhead “Time and Payment of Claims,” the policy states that “Claims will be paid promptly upon receipt of proper written proof and determination that benefits are payable.” (Italics added.) This is immediately followed by the subhead, “Payment of Claims,” which states: “Participating Providers and Preferred Providers are paid directly by Blue Shield Life, [f] If the Insured receives Services from a Non-Preferred Provider, payment will be made directly to the Subscriber, and the Insured is responsible for payment to the Non-Preferred Provider . . . .”
We distill this language as follows. First, the policy states that claims are submitted in two ways—by both the insured and by preferred providers. No meaningful distinction between the two claims submission mechanisms is evident. Second, the policy goes on to state that claims—which now presumably include those made by a provider or a poliсyholder—are paid upon “proper written proof.” The policy’s limitation provision then states that an action may not be brought until 60 days after “written proof of claim” has been filed. We conclude that a reasonable insured would read these provisions together to mean that all claims, whether made by the insured or a preferred provider, require written proof, and that the time to sue begins to run after a claim is submitted in either manner.
As to the second, Blue Shield cites inapplicable decisions concerning the type of proof required to show that a party either waived or was estopped from relying on certain contract provisions. Blue Shield also relies on Code of Civil Procedure section 360.5, which provides that the statute of limitations may not be waived for longer than four years, and only then by an agreement signed by the waiving party. It is not clear to us that this statute applies to a contract provision that does not waivе the statute of limitations, but instead merely purports to fix it for actions arising from the agreement. Assuming for the sake of argument that Code of Civil Procedure section 360.5 does apply in this setting, we conclude that the policy’s extended limitations clause complies with that provision because it is in writing and the policy was signed by both the secretary and president of Blue Shield.
Finally, Blue Shield relies on the doctrine of noscitur a sociis: that a word takes its meaning from the company it keeps. (Credit Suisse First Boston Mortgage Capital, LLC v. Darning, Gill, Diamond & Kollitz (2009)
In short, instead of using the language set forth in section 10350.11, Blue Shield drafted a policy provision that a reasonable insured would read as providing a three-year time limit to sue for any matters arising out of the policy, regardless of the nature of the remedies sought.
The petition is denied. Real party in interest shall recover her appellate costs.
Flier, J., and Grimes, J., concurred.
Notes
Claims for breach of the implied covenant of good faith and fair dealing may sound in either contract or tort, depending on the remedies being sought. A contrаct claim limits the plaintiff to contract remedies only, while a tort claim permits recovery of noncontract damages, such as emotional distress, punitive damages, and attorney’s fees. (Archdale v. American Internat. Specialty Lines Ins. Co. (2007)
Our decision addresses the statute of limitations and related contract provision only. We express no opinion on the merits of Kawakita’s claims.
Kawakitа also sued Stendel and the agency where he worked for negligence and fraud. They are not parties to this writ proceeding.
All further undesignated section references are to the Insurance Code.
We set forth the exact language of both section 10350.11 and the Blue Shield policy limitations provision as part of our discussion.
These provisions are part of a uniform act adopted by California and 41 other states, Puerto Rico and the Virgin Islands. (See Wetzel v. Lou Ehlers Cadillac Group Long Term Disability Ins. Program (9th Cir. 2000)
The Wetzel court cited NN Investors Life Ins. Co. v. Superior Court (1989)
Although Flynn was unpublished and therefore not citable in federal court, it may serve as persuasive authority in California’s state courts. (Roskind v. Morgan Stanley Dean Witter & Co. (2000)
The policy at issue in Heighley was for accidental death, which is also considered a disability policy subject to the provisions of sections 10350 through 10354. (§ 106, subd. (a).)
Although the NN Investors Life court never mentioned section 10350.11, the action arose from a health insurance policy and the decision quoted a policy provision that was virtually identical to the language of that statute. (NN Investors Life, supra, 208 Cal.App.3d at pp. 1073-1074.)
Another decision cited by Blue Shield is Mize, supra,
While section 10350 states that different language not less favorable than the statutory provisions is allowed, section 10390 states that policy provisions in conflict with that chapter of the Insurance Code would still be governed by that chapter. We asked for and received supplemental briefing from the parties concerning whether section 10350 could be construed to permit the use of more favorable provisions, as opрosed to provisions with different wording which were substantially equivalent to the statutorily prescribed terms. No reported decision, and nothing in the legislative history, addresses this issue. Kawakita contends, and Blue Shield somewhat reluctantly concedes, that an insurer may substitute a more favorable limitations period that extends the time period for bringing a tortious bad faith claim. This is consistent with the well-established principle that the parties to a contract may agree to shorten or extend the statute of limitations. (See generally Hambrecht & Quist Venture Partners v. American Medical Internal., Inc. (1995)
Blue Shield contends, for the first time on appeal, that there is no evidence it ever received approval from the Insurance Commissioner to use language that differed from section 10350.11. Because Blue Shield did not raise the issue in the trial court, it was waived. (North Coast Business Park v. Nielsen Construction Co. (1993)
At one time, actions for tortious bad faith were not considered actions on a policy for purposes of an insurance policy’s shortened limitations period for such actions. (Frazier v. Metropolitan Life Ins. Co. (1985)
Blue Shield contends that its use of the term “arising out of the Plan" must be read as a reference to contract-related claims. This contention ignores the preceding phrase “or any other matter.”
Therefore, we disagree with the trial court’s conclusion that the policy’s limitation provision was exactly the same as section 10350.11. As noted earlier, however, we review the trial court’s ruling, not its rationale.
Blue Shield’s summary adjudication motion included a declaration from litigation specialist Leslie Crawford stating that Blue Shield received claims for Kawakita’s surgery from her medical providers. It is therefore undisputed that claims were submitted in that manner.
We also note that under section 10350.5, disability policies must state that a notice of claim “given by or on behalf of the insured . . . shall be deemed notice to the insurer.” (Italics added.) Blue Shield’s claim notice provision did not include this language, but our interpretation makes it accord with the statutory requirement.
Furthermore, Blue Shield’s interpretation would leave policyholders without guidance as to the limitation period for suits brought when claims filed by preferred providers are denied. The result of such an interpretation is unclеar, but, arguably, the three-year limitation period would evaporate, leaving the statutory two-year period for tortious bad faith claims, while also reinstating the statutory four-year period for breach of contract claims. In other words, there would be a contractual limitations period of three years based on denied claims when those claims were for services rendered by a nonpreferred provider and the insured filed the claim, and some unstated limitations period for denied claims for services rendered by a preferred provider and the provider filed the claim. As Blue Shield itself noted at oral argument, such a result would be nonsensical.