Justia Washington Supreme Court Opinion Summaries

John and Michelle Strauss challenged the Court of Appeals decision affirming summary dismissal of their action against Premera Blue Cross, which arose out of the denial of coverage for proton beam therapy (PBT) to treat John's prostate cancer. At issue was whether the Strausses established the existence of a genuine issue of material fact regarding PBT's superiority to intensity-modulated radiation therapy (IMRT), thereby demonstrating that proton beam therapy was "medically necessary" within the meaning of their insurance contract. The Washington Supreme Court determined they did, and therefore reversed the Court of Appeals' decision, and remanded for a jury trial on the disputed facts. View "Strauss v. Premera Blue Cross" on Justia Law

Christopher Floeting alleged a Group Health Cooperative employee repeatedly sexually harassed him while he was seeking medical treatment. He sued Group Health for the unwelcome and offensive sexual conduct under the Washington Law Against Discrimination, which made it unlawful for any person or the person's agency or employee to commit an act of discrimination in any place of public accommodation. The trial court dismissed on summary judgment, pursuant to Group Health's argument the employment discrimination standard applied. The Court of Appeals reversed. Group Health argued the Washington Supreme Court should import workplace sexual harassment doctrines into the public accommodations context, thereby limiting its employer liability. Declining to do so, the Supreme Court affirmed the appellate court. View "Floeting v. Grp. Health Coop." on Justia Law

In 2006, the Washington legislature enacted legislation establishing a state health technology assessment program. Part of that legislation formed the Health Technology Clinical Committee ("HTCC") as an independent committee to judge selected medical technology and procedures by their safety, efficacy, cost-effectiveness, and health outcomes. In 2010, the HTCC began its review of a controversial procedure - femoroacetabular impingement (FAI) syndrome hip surgery. Michael Murray sustained a hip injury while at work in August 2009. L&I allowed his claim and provided medical treatment. Murray's physician, Dr. James Bruckner, asked the Washington Department of Labor and Industries ("L&I") to authorize surgery regarding Murray's hip condition, FAI syndrome. L&I denied payment for FAI surgery because the HTCC disallowed coverage for that procedure. Dr. Bruckner performed the surgery on Murray without authorization from L&I. The FAI surgery purportedly successfully rehabilitated Murray's hip injury. Murray appealed L&I's decision denying payment for the surgery to the Board of Industrial Insurance Appeals (Board or BIIA), which affirmed L&I. Murray appealed to the superior court, which affirmed the Board. Murray appealed to the Court of Appeals, which affirmed the superior court. Murray then petitioned the Washington Supreme Court, which reversed. The Supreme Court "harmonized" the HTCC legislation with the Industrial Insurance Act, and in doing so, determined that applying L&I's Medical Aid Rules, HTCC determinations were one of several sources of information L&I used to make medical coverage decisions. "While HTCC determinations are given considerable weight, the Medical Aid Rules do not afford such determinations preclusive effect. Under Medical Aid Rules, L&I, not the HTCC, remains responsible for medical treatment coverage decisions. Accordingly, such Department medical coverage decisions are then subject to review before the BIIA and in superior court, pursuant to chapter 51.52 RCW." Murray's reimbursement claim to L&I was remanded for further proceedings. View "Murray v. Dep't of Labor & Indus." on Justia Law

Victor and Deanna Zandi's were divorced in 2009. Their dependent daughter, T.Z., incurred approximately $13,000 in medical bills when she had a kidney stone removed while traveling outside her medical insurer’s, Kaiser Permanente, network. The superior court ordered Victor Zandi to pay 7 5 percent of the cost and Deanna Zandi to pay the remaining 25 percent. The Court of Appeals reversed, finding that the superior court abused its discretion by modifying the parties' 2009 order of child support, which required Victor Zandi to pay 100 percent of "uninsured medical expenses." This case presented an issue of whether out-of-network health care costs qualified as "[u]ninsured medical expenses" under RCW 26.18.170(18)(d). The Supreme Court affirmed the Court of Appeals: the legislature defined "[u]ninsured medical expenses" as costs not covered by insurance. WAC 388-14A-1020 clarified that this included costs "not paid" by insurance, even if those costs would be covered under other circumstances. Because the health care expenses in this case were unambiguously within the scope of RCW 26.18.170(18)(d), financial responsibility was allocated by the 2009 order and may not be modified absent evidence of changed circumstances or other evidence consistent with the requirements of RCW 26.09.170(6)-(7). View "In re Marriage of Zandi" on Justia Law

In this case, a manufacturer sold a surgical device to a hospital, which credentialed some of its physicians to perform surgery with the device. The manufacturer's warnings regarding that device were at the heart of this case: whether the manufacturer owed a duty to warn the hospital that purchased the device. The manufacturer argued that since it warned the physician who performed the surgery, it had no duty to warn any other party. The Supreme Court disagreed because the doctor was often not the product purchaser. The Court found that the WPLA required manufacturers to warn purchasers about their dangerous medical devices. “Hospitals need these warnings to credential the operating physicians and to provide optimal care for patients. In this case, the trial court did not instruct the jury that the manufacturer had a duty to warn the hospital that purchased the device. Consequently, we find that the trial court erred.” View "Taylor v. Intuitive Surgical Inc." on Justia Law

Ho Im Bae died from acute morphine intoxication at Lakeside Adult Family Home. Esther Kim, the personal representative of Bae's estate, brought tort claims against several individuals involved in Bae's care. The issue this appeal presented for the Supreme Court's review came from Alpha Nursing & Services Inc. and two of its nurses, who did not provide nursing services to Bae, but who were alleged to have observed signs of abuse and physical assault that should have been reported to the Department of Social and Health Services (DSHS) and law enforcement. Specifically, the issue was whether the abuse of vulnerable adults act (AVAA) created an implied cause of action against mandated reporters who fail to report abuse. The trial court granted the defendants' motion for summary judgment. The Court of Appeals affirmed, holding that one of the nurses did not have a duty to report and the other nurse fulfilled her reporting duty by contacting DSHS. After review, the Supreme Court reversed the Court of Appeals on this issue: "[t]he AVAA creates a private cause of action against mandated reporters who fail to report abuse, and genuine issues of material fact preclude summary judgment." A separate issue was whether the claims against one of the nurses should have been dismissed for insufficient service. The nurse, Christine Thomas, moved to Norway, and plaintiff personally served her there almost a year after filing and amended complaint and properly serving Alpha. The Supreme Court affirmed the trial court's denial of the nurse's motion to dismiss: "Consistent with Norway's ratification of the Hague Convention, however, the plaintiff acted with reasonable diligence in serving Thomas through Norway's designated central authority." View "Kim v. Lakeside Adult Family Home" on Justia Law

The plaintiffs' complaint alleged that two groups of defendants, (1) Premera, Premera Blue Cross, and Life Wise Health Plan of Washington (collectively Premera) and (2) the Washington Alliance for Healthcare Insurance Trust and its trustee, F. Bentley Lovejoy (collectively WAHIT), colluded and made false and misleading representations to the plaintiffs that induced the plaintiffs to purchase health insurance policies under false pretenses. Plaintiff-policyholders claimed that Premera and WAHIT violated the Washington Consumer Protection Act (CPA). The plaintiffs requested only two specific forms of damages: (1) for the "unfair business practices and excessive overcharges for premiums," the plaintiffs requested "the sum of the excess premiums paid to the defendants;" and (2) "[i]f the surplus is excessive and unreasonable," the plaintiffs asserted that "the amount of the excess surplus should be refunded to the subscribers who have paid the high premiums causing the excess." On Premera and WAHIT's motion, the trial court dismissed the Policyholders' suit in its entirety based on the filed rate, primary jurisdiction, and exhaustion of remedies doctrines. Specifically, the trial court dismissed all claims of class B (small group) and class C (individuals) pursuant to CR 12(b )( 6) and dismissed all claims of class A (large group) on summary judgment under CR 56. The Court of Appeals reversed the trial court in relation to certain of the Policyholders' CPA claims. Because awarding the specific damages requested by the plaintiffs would require a court to inappropriately substitute its judgment for that of the Office of the Insurance Commissioner (OIC), the Supreme Court affirmed the trial court's dismissal of the plaintiffs' claims. View "McCarthy Fin., Inc. v. Premera" on Justia Law

In 1989, the Washington Legislature mandated coverage for neurodevelopmental therapies (neurodevelopmental therapies or NOT) (speech, occupational, and physical therapy) in employer-sponsored group plans for children under age seven (RCW 48.44.450). In 2005, the legislature enacted the mental health parity act, which mandated coverage for "mental health services" (RCW 48.44.341). The two named plaintiffs in this case, O.S.T. and L.H. were young children diagnosed with some form of neurodevelopmental issues. Both plaintiffs at some point were insured under health policies issued by Regence BlueShield that contained blanket exclusions for neurodevelopmental therapies. Regence BlueShield did not cover O.S.T.'s therapies, so O.S.T.'s parents paid for the services. It was unclear whether Regence BlueShield denied any of L.H.'s claims. Plaintiffs filed a class-action complaint, alleging breach of contract; declaratory relief; violation of the Washington Consumer Protection Act, chapter 19.86 RCW; and seeking injunctive relief. The trial court granted partial summary judgment to the plaintiffs in late 2012, holding that "any provisions contained in Regence BlueShield policies issued and delivered to Plaintiffs O.S.T. and L.H. on or after January 1, 2008 that exclude coverage of neurodevelopmental therapies regardless of medical necessity are declared invalid, void and unenforceable by Defendant and its agents." The Court of Appeals granted discretionary review, and the Supreme Court accepted transfer. Upon review, the Supreme Court held that the statutes did not conflict, and that neurodevelopmental therapies could constitute "mental health services" if the therapies are medically necessary to treat a mental disorder identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th rev. ed. 2000) (DSM-IV-TR). Therefore, the blanket exclusions of neurodevelopmental therapies in the plaintiffs' health contracts were void and unenforceable. View "O.S.T. v. Regence BlueShield" on Justia Law

In this class action lawsuit, the trial court found that the State wrongfully denied health benefits to a number of its part-time employees. The issue this case presented for the Supreme Court's review was how to value the damages suffered by that group of employees when they were denied health benefits. The State argued that the only damages to the employees were immediate medical expenses paid by employees during the time they were denied health benefits. But evidence showed that people denied health care benefits suffer additional damage. They often avoid going to the doctor for preventive care, and they defer care for medical problems. This results in increased long-term medical costs and a lower quality of life. Based on this evidence, the trial court correctly rejected the State's limited definition of damages because it would significantly understate the damages suffered by the employees. The Supreme Court affirmed. View "Moore v. Health Care Auth." on Justia Law

Christiana Anaya suffered from uncontrolled diabetes, which left her susceptible to serious infections. She went to the Toppenish Community Hospital with a urinary tract infection. Blood test results revealed Ms. Anaya had a yeast infection. The lab called Ms. Anaya's primary care facility (the Yakima Valley Farm Workers Clinic) where Respondent Dr. Mark Sauerwein was covering for Ms. Anaya's usual provider. Sauerwein was concerned about the lab results. Due to the serious nature of a blood infection, the doctor decided that if Ms. Anaya was feeling ill, she should come in immediately for treatment. If she was feeling better, it was more likely that the test result was a false positive, a common occurrence in microbiology labs. Dr. Sauerwein used the complete clinical picture available to him to conclude that the lab result was a false positive resulting from contamination but had the nurse contact Mrs. Anaya to move her next appointment up to the following week. Dr. Sauerwein did not tell Mrs. Anaya about the test result. The lab positively identified candida glabrata as the yeast in Ms. Anaya's blood. An infection of glabrata in the blood is serious. Lab microbiologists entered this information into Ms. Anaya's medical record but did not notify Dr. Sauerwein, the Clinic, or anyone else about the positive test result. Before Ms. Anaya's next visit to the Clinic, her condition worsened. Ms. Anaya went to Yakima Memorial Hospital where she was prescribed amphotericin B, which is highly toxic to the kidneys. Given the compromised state of Ms. Anaya's kidneys from her diabetes, a health care provider would not normally prescribe amphotericin B until positively identifying glabrata. Unfortunately, the amphotericin B treatment came too late to stop the infection from spreading to the internal organs. Ms. Anaya died at age 32 of cardiac arrest, deprivation of oxygen to the brain, and fungal sepsis; all stemming from type II diabetes mellitus. Mr. Anaya Gomez, as personal representative of Ms. Anaya's estate, filed suit against Dr. Sauerwein and the Clinic for malpractice. Three weeks before the jury trial, the estate moved to add a claim for failure to obtain informed consent. At the close of Mr. Anaya's case, the defense moved for judgment as a matter of law on the informed consent claim. The trial judge granted the motion and dismissed the informed consent claim, arguing that case law precluded the claim in misdiagnosis cases. The jury then found Dr. Sauerwein did not breach any duty owed to Ms. Anaya. After its review, the Supreme Court concluded that when a health care provider rules out a particular diagnosis based on the patient's clinical condition-including test results, medical history, presentation upon physical examination, and any other circumstances surrounding the patient's condition that are available to the provider the provider may not be liable for informed consent claims arising from the ruled out diagnosis. The Court affirmed the appellate court, which affirmed the trial court's judgment. View "Gomez v. Sauerwein" on Justia Law