LOS ANGELES (CN) - Kaiser Permanente Health Plan failed to pay a man's medical expenses, and then attempted to get its hands on his settlement money, he claims in California Superior Court.
Jesse Cox was shot by a stray bullet while waiting in line at a restaurant drive-thru, leading to a five-day stay at Providence Holy Cross Medical Center in Mission Hills and a $300,000 medical bill that should have been paid by Kaiser, Cox says in his complaint.
Cox subsequently won a $300,000 settlement with the restaurant for failure to provide adequate safety measures for patrons, but alleges that Kaiser is illegally trying to get a big chunk of the dough.
"Not until the end of underlying litigation did defendant Kaiser, by and through its agent and joint venturer, defendant Rawlings, deceptively and unfairly claim a lien and subrogation rights to the proceeds of any settlement in the underlying personal injury action," the complaint states.
The Rawlings Group specializes in healthcare subrogation, or "recovery," services. Cox says Kaiser is using the company to obtain a portion of his settlement.
"Defendant Kaiser, by and through defendant Rawlings, has repeatedly asserted that they are entitled to $100,000 from the settlement proceeds, wholly ignoring the required reduction for costs and attorney fees, despite this being brought to their attention on multiple occasions," the complaint states.
Cox adds that Rawlings "has several times intentionally misled plaintiff's counsel into believing that they were in contact with defendant Kaiser on a regular basis and that their counsel was licensed in California," and that both Kaiser and Rawlings "knew that there was no basis for the claims they were asserting and have utterly failed to provide evidence pursuant to California Civil Code, that defendant Kaiser's lien claim is based upon the reasonable costs of medical services which were actually paid by any of the defendants herein."
Cox says he has received no proof that Kaiser has paid any of the bill. Under California law, "no lien asserted by a medical group, such as defendant Kaiser, may exceed the sum of the reasonable costs actually paid by the medical group," the complaint says.
Cox says "defendants refused to provide proof of payment actually made because in fact no payment for services was made by any of the defendants herein to any of plaintiff's underlying healthcare providers."
Cox is suing for breach of contract, breach of duty of good faith and fair dealings, fraud and for violation of California's Business & Professions Code. He seeks consequential, general, special, punitive and exemplary damages.
Philip J. Layfield and Jamie L. Keeton of El Segundo represent the plaintiff.
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