Arce v. Kaiser Foundation Health Plan, Inc.

181 Cal. App. 4th 471 (2010)

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Arce v. Kaiser Foundation Health Plan, Inc.

California Court of Appeal
181 Cal. App. 4th 471 (2010)

Facts

Andrew Arce (plaintiff) was a four-year-old boy with autism and was a member of a health plan provided by Kaiser Foundation Health Plan, Inc., the Permanent Medical Group, Inc., and Southern California Permanente Medical Group, Inc. (collectively, Kaiser) (defendants). Kaiser’s plan provided coverage for healthcare services and excluded coverage of custodial care. Acting through his father, Arce brought a class-action suit against Kaiser in state trial court. Arce alleged that Kaiser’s plan covered applied-behavior-analysis (ABA) therapy and speech therapy to treat autism and that Kaiser breached its health-plan contract by categorically denying coverage of these therapies to plan members with autism. Arce alleged that Kaiser had a pattern and practice of denying coverage of ABA and speech therapy for autism on the grounds that the therapies were not healthcare services or were custodial care. Kaiser demurred to the claim, arguing that resolution of the claim would require the trial court to make individualized determinations of medical necessity, which would defeat the community-of-interest requirement for class claims. The trial court sustained Kaiser’s demurrer. Arce appealed.

Rule of Law

Issue

Holding and Reasoning (Zelon, J.)

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