Van Ness v. Blue Cross of California

Opinion

REARDON, Acting P. J.

In 1991 appellant Richard Van Ness purchased health insurance from respondent Blue Cross of California under its prudent buyer program. That program established a two-tiered benefit schedule—the negotiated fee schedule for participating providers and the limited fee schedule for nonparticipating providers. Benefits under the negotiated fee schedule were greater because network providers agreed to cap their fees for Blue Cross subscribers. Van Ness’s treating physician was not part of the prudent buyer network.

When the benefits Blue Cross paid for colonoscopy…