Garcia v. PacifiCare of California

Summarized by:

  • Court: 9th Circuit Court of Appeals Archives
  • Area(s) of Law: Insurance Law
  • Date Filed: 05-08-2014
  • Case #: 13-55468
  • Judge(s)/Court Below: Circuit Judge Christen for the Court; Circuit Court Judges Reinhardt, and Kleinfeld.
  • Full Text Opinion

A health insurance company’s refusal to cover myoelectric prosthetics is not a violation of California Health and Safety Code §1367.18.

Martha Garcia contracted spinal meningitis at the age of 11 in 1989. The illness resulted in the amputation of her hands and legs. After the illness, Garcia utilized myoelectric upper-extremity prostheses, which allowed her to live relatively independently. In 2006 Garcia was hired at the Regional Center of Orange County. At the time, she was included on her father’s health insurance policy that provided coverage for her prostheses. Upon gaining employment, Garcia switched to the health care plan offered by her employer, PacifiCare, because it allowed her to continue seeing her familiar doctors and provided similar coverage. In 2009, Garcia’s prostheses began to fail and her new insurance company denied her doctor’s request for a new myoelectronic prosthetic. Garcia brought suit against PacifiCare, alleging that the exclusion of her benefits was contrary to California Health and Safety Code §1367.18 (the "Code"). The district court granted summary judgment for PacifiCare and this appeal followed. The issue is one of statutory interpretation and the Ninth Circuit looked to the text and the history of the code to determine whether the code was violated. PacifiCare argued that the code should be interpreted to mean that some type of prosthetics must be offered by insurance companies, but the type of prosthetics covered are subject to the insurer’s discretion. Garcia argued that the code mandates coverage of any and all prosthetics proscribed by physicians that are determined to be medically necessary. The panel looked at the text of the code in its entirety and determined that the legislature did not intend to mandate coverage of all prosthetics, but merely meant to require insurance companies to replace defective prosthetics when coverage was already provided. Therefore, Pacificare did no violate the Code when it denied Garcia's request for the myoelectric prostheses.

AFFIRMED.

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