Victims of Fraud Should Always Fight Back Proactively

Post 5398

Cross-Claim Against Fraudsters Successful

In Dual Diagnosis Treatment Center, Inc., et al. v. Health Net, Inc., et al., Health Net Life Insurance Company, B331260, California Court of Appeals, Second District, Third Division (July 16, 2026) a trial verdict in favor of Health Net and against Sovereign, a network of mental health and substance use disorder treatment centers, and Health Net, Inc., Health Net of California, Inc., Health Net Life Insurance Company, and Managed Health Network, Inc. (collectively, Health Net) was appealed to the California Court of Appeals.

FACTUAL BACKGROUND

Between 2014 and 2016, Sovereign submitted claims to Health Net for medical care provided to more than 400 patients. Health Net paid some claims but rejected many others. Sovereign, as the patients’ assignee, sued Health Net for breach of contract, insurance bad faith, and breach of the Employee Retirement Income Security Act of 1974 (ERISA).

Health Net cross-claimed for fraud, intentional interference with contractual relations, and unfair competition, among other things.

Health Net paid some claims but rejected many others. Health Net alleged Sovereign carried out a broad insurance-fraud scheme involving illegal patient referral fees, false residency information, premium payments and cost-sharing waivers concealed from Health Net, unnecessary services, falsified records, and inflated billing.

Before trial, the court found Sovereign had paid unlawful referral fees for more than 300 patients. After a seven-week jury trial and a later bench trial on equitable claims, judgment was entered for Health Net, including substantial damages and restitution against Sovereign and Dr. Sharma.

LAW:

The court applied California rules governing summary adjudication, the Unfair Competition Law (UCL), Insurance Code section 750, unclean hands, fraud, insurance bad faith damages, ERISA exhaustion principles, and appellate prejudice.  A UCL plaintiff must show economic injury and loss of money or property but need not prove a precise amount at the standing stage.

The UCL may reach unlawful, unfair, or fraudulent business practices. The unclean-hands doctrine may bar relief in legal and equitable actions when the plaintiff’s misconduct directly relates to the transaction at issue and makes recovery inequitable.

Civil judgments are not reversed for procedural, evidentiary, instructional, or damages-related error absent a showing of prejudice.

DISCUSSION:

On appeal, Sovereign challenged the pretrial UCL ruling, the summary adjudication of Health Net’s fraud and unclean-hands defenses, several jury instructions, exclusion of California Department of Insurance materials, the ruling limiting bad-faith damages, and the judgment on ERISA claims.

The Court of Appeal emphasized that Sovereign’s briefing failed to fairly summarize the extensive trial record, limiting appellate review. The court held that any possible error in the pretrial UCL ruling was harmless because the trial court later found, after trial, an independent basis for restitution under the unfair and fraudulent prongs of the UCL. It also concluded Sovereign failed to show error in the unclean-hands ruling, because the illegal referral payments directly related to the claims for payment arising from those same referred patients.

ANALYSIS:

The decision turned on Sovereign’s inability to show reversible prejudice. The appellate court repeatedly held that even if certain rulings were questionable, Sovereign did not demonstrate a reasonable probability of a more favorable result.

The unclean-hands holding is especially important because it allowed the court to bar recovery by the assignee based on the assignee’s own misconduct, even though the patients themselves were not alleged to have acted wrongfully.

The court also treated the trial findings of pervasive fraudulent business practices as supporting restitution beyond the patients obtained through illegal referral fees.

CONCLUSION

Sovereign admitted that it paid consultants for patient referrals, but contended that the practice was lawful and known to Health Net. Sovereign thus urged that Health Net was not harmed by the payment of referral fees because it would have been responsible for claims in the same amounts even if treatment had been rendered by other providers.

The Court of Appeal affirmed the judgment in full. Sovereign did not establish prejudicial error as to the UCL ruling, unclean-hands defense, jury instructions, evidentiary exclusions, Brandt-fee ruling, or ERISA claims. In addition  Respondents were awarded appellate costs.

ZALMA OPINION

People who have perpetrated insurance fraud and deceived their clients have the unmitigated gall to sue the clients they were defrauding. Usually, the victims will defend aggressively or seek to negotiate a settlement. Healthnet did not settle, did not negotiate, it cross-claimed and established the unlawful conduct, an action that worked and took the profit out of the fraud and attempted fraud.

(c) 2026 Barry Zalma & ClaimSchool, Inc.

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