California Spine and Neurosurgery Institute has filed a complaint against Boston Scientific Corporation, alleging breach of an oral contract and promissory estoppel. The lawsuit was filed in the Santa Clara County Superior Court on May 23, 2024, by California Spine and Neurosurgery Institute against Boston Scientific Corporation.
The dispute arose when California Spine performed surgery on a patient insured through an employee health benefit plan sponsored by Boston Scientific. After the surgery, California Spine sought reimbursement for its services but was denied by the benefit plan. Instead of appealing through the plan’s internal process or asserting a claim under the Employment Retirement Income Security Act (ERISA), California Spine chose to sue Boston Scientific for breach of an alleged oral contract independent of the benefit plan and for promissory estoppel.
California Spine is owned by Dr. Adebukola Onibokun, a neurosurgeon specializing in spine surgeries. The institute does not participate in any preferred provider organization plans or health maintenance organization plans, making it an out-of-network provider. In early March 2018, a patient covered under Boston Scientific’s ERISA-governed employee health plan scheduled an office visit with California Spine. Prior to this visit, California Spine verified the patient's benefits through an online portal named Availity and confirmed coverage details via phone calls with Blue Cross and Blue Shield of Massachusetts (Blue Cross).
During these verification calls, Brandy Wright, California Spine’s office manager, was informed that there was “a 40% co-insurance after deductible” and that reimbursement rates would be based on “usual, customary and reasonable” (UCR) rates rather than Medicare rates. Following this assurance, Dr. Onibokun performed surgery on the patient in April 2018. However, when California Spine submitted claims totaling $77,000 to Blue Cross for reimbursement, only $1,970.36 was approved due to the patient's deductible.
California Spine's claims manager attempted to appeal this decision but was informed that they needed to complete Blue Cross' internal appeal process before formally appealing to Boston Scientific under the patient's benefit plan. Instead of following this procedure, California Spine filed a lawsuit alleging that they were assured payment at UCR rates independent of the benefit plan during verification calls.
The trial court granted summary judgment in favor of Boston Scientific on March 8, 2022. The court ruled that there was no evidence of an oral contract independent of the benefit plan and dismissed California Spine's promissory estoppel claim due to lack of a clear promise from Boston Scientific outside the terms of their benefit plan.
California Spine appealed this decision but did not file a separate notice regarding costs awarded to Boston Scientific amounting to $8,974.12. Consequently, their challenge to the costs order is not within appellate jurisdiction as it wasn't included in their initial notice or subsequent appeals.
Attorneys involved include those representing both parties in various capacities throughout multiple stages including initial filings and appeals processes. The case ID is H049966 with Judge Bromberg presiding over final decisions alongside Acting P.J., Grover and J., Lie concurring.