Centinela Freeman etc. v. Health Net of California, S218497

Health care: Emergency medical services: HMO: Both state and federal law require any licensed hospital that has appropriate facilities and qualified personnel to provide emergency medical services or care regardless of a patient’s ability to pay. (Health & Saf. Code, § 1317, subds. (a), (b); 42 U.S.C. § 1395dd (b), (h).) If the patient is an enrollee in a health care service plan, the plan is required by statute to reimburse the emergency service provider for necessary emergency medical services and care. (§ 1371.4, subd. (b).) Plans are permitted, however, to delegate this financial responsibility to their contracting medical providers. (§ 1371.4, subd. (e), hereafter section 1371.4(e).)

Health care service plans are defined in section 1345, subdivision (f). They are commonly known as health maintenance organizations or HMOs. (Watanabe v. California Physicians’ Service (2008) 169 Cal.App.4th 56, 59, fn. 3.) 

(Cal. S.C., November 14, 2016, Centinela Freeman etc. v. Health Net of California, S218497).

Décision qui expose de manière complète les diverses responsabilités financières des intervenants dans la chaîne du système de santé, et les conséquences en cas de défaillance économique de l’un d’eux.

Centinela Freeman etc. v. Health Net of California, S218497

Third parties: Negligence, Tort, Privity of contract:

Although “recognition of a duty to manage business affairs so as to prevent purely economic loss to third parties in their financial transactions is the exception, not the rule, in negligence law, privity of contract is no longer necessary to recognition of a duty in the business context and public policy may dictate the existence of a duty to third parties.” (Quelimane Co. v. Stewart Title Guaranty Co. (1998) 19 Cal.4th 26, 58 (Quelimane).) The test for determining the existence of such an exceptional duty to third parties is set forth in the seminal case of Biakanja, supra, 49 Cal.2d at page 650, as follows: “The determination whether in a specific case the defendant will be held liable to a third person not in privity is a matter of policy and involves the balancing of various factors, among which are [1] the extent to which the transaction was intended to affect the plaintiff, [2] the foreseeability of harm to him, [3] the degree of certainty that the plaintiff suffered injury, [4] the closeness of the connection between the defendant’s conduct and the injury suffered, [5] the moral blame attached to the defendant’s conduct, and [6] the policy of preventing future harm.”

(Cal. S.C., November 14, 2016, Centinela Freeman etc. v. Health Net of California, S218497).

Responsabilité contractuelle en faveur d’un tiers lésé ?

Est exceptionnelle la reconnaissance d’un devoir de gérer ses affaires commerciales de manière à éviter une perte économique au détriment d’un tiers au contrat. Un tel devoir peut cependant exister, même en faveur d’un tiers sans proximité avec le contrat. En particulier, l’intérêt public peut dicter un tel devoir. Le test pour déterminer son existence découle de la jurisprudence Biakanja. Il dispose que la reconnaissance de ce devoir s’examine au cas par cas et implique d’apprécier différents facteurs, dont (1) l’intention des parties d’affecter les intérêts du demandeur, (2) la prévisibilité du dommage causé au tiers, (3) le degré de certitude du dommage allégué, (4) l’intensité de la causalité entre la conduite du défendeur et le dommage subi, (5) le reproche moral attaché à la conduite du défendeur, (6) l’intérêt à prévenir un dommage futur.