Title: Cal. Medical Assn. v. Aetna Health of Cal., Inc.
Citation: N/A
Docket Number: S269212
State: California
Issuer: California Supreme Court
Date: July 17, 2023

IN THE SUPREME COURT OF 
CALIFORNIA 
 
CALIFORNIA MEDICAL ASSOCIATION, 
Plaintiff and Appellant, 
v. 
AETNA HEALTH OF CALIFORNIA INC., 
Defendant and Respondent. 
 
S269212 
 
Second Appellate District, Division Eight 
B304217 
 
Los Angeles County Superior Court 
BC487412 
 
 
July 17, 2023 
 
Justice Evans authored the opinion of the Court, in which 
Chief Justice Guerrero and Justices Corrigan, Liu, Kruger, 
Groban, and Jenkins concurred. 
 
1 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH 
OF CALIFORNIA INC. 
S269212 
 
Opinion of the Court by Evans, J. 
 
The California Medical Association, a professional 
association representing California physicians, has sued a 
health insurance company, alleging the company violated the 
unfair competition law (UCL; Bus. & Prof. Code, § 17200 et seq.) 
by engaging in unlawful business practices.  The UCL confers 
standing on a private plaintiff to seek relief under the statute 
only if that plaintiff has “suffered injury in fact” and “lost money 
or property as a result of the unfair competition” at issue.  (Bus. 
& Prof. Code, § 17204.)1  This case presents the question 
whether an organization can satisfy these two related standing 
requirements by diverting its own resources to combat allegedly 
unfair competition.   
The issue arises here because, under the UCL as it was 
amended in 2004 by Proposition 64, a membership organization 
such as the California Medical Association may not base 
standing to sue on injuries to its members, but only on those to 
the organization itself.  (Amalgamated Transit Union, Local 
1756, AFL-CIO v. Superior Court (2009) 46 Cal.4th 993, 1003–
1004 (Amalgamated Transit).)  And, while an organization 
would clearly have standing under the UCL if it were, for 
example, fraudulently induced to buy a product from a deceptive 
 
1  
Unless otherwise specified, statutory references are to the 
Business and Professions Code. 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
2 
seller (see § 17201 [broadly defining “person[s]” who can sue 
under the UCL]), this case presents us with a more difficult 
question:  whether resources that an organization has spent to 
counter an unfair or unlawful practice constitute “money or 
property” that has been “lost . . . as a result of the unfair 
competition.”  (§ 17204.)   
We hold that the UCL’s standing requirements are 
satisfied when an organization, in furtherance of a bona fide, 
preexisting mission, incurs costs to respond to perceived unfair 
competition that threatens that mission, so long as those 
expenditures are independent of costs incurred in UCL 
litigation or preparations for such litigation.  When an 
organization has incurred such expenditures, it has “suffered 
injury in fact” and “lost money or property as a result of the 
unfair competition.”  (§ 17204.)  In this case, which arises on 
appeal from summary judgment for the defense, the record 
discloses a triable issue of fact as to whether the plaintiff 
association expended resources in response to the perceived 
threat the health insurer’s allegedly unlawful practices posed to 
plaintiff’s mission of supporting its member physicians and 
advancing public health.  The evidence was also sufficient to 
create a triable issue of fact as to whether those expenses were 
incurred independent of this litigation.  For these reasons, the 
trial court erred in granting summary judgment for the defense.  
We therefore reverse the judgment of the Court of Appeal, which 
affirmed the grant of summary judgment. 
I.  FACTUAL AND PROCEDURAL BACKGROUND 
Defendant Aetna Health of California Inc. (Aetna) provides 
health insurance.  For its preferred provider plans, Aetna 
contracts with a network of physicians and other medical 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
3 
providers who offer care to insured individuals at an agreed 
rate.  Member patients can also see providers outside the 
network on referral from in-network physicians, but may bear a 
greater share of the cost.  Effective in 2009, Aetna adopted a 
“Network Intervention Policy” designed, according to its terms, 
to “reduce the number of non par [i.e., nonparticipating, or 
out-of-network] referrals by par providers and if necessary take 
further action against participating providers who refuse, after 
warning and education to comply with the terms of their 
contract.”  (See California Medical Assn. v. Aetna Health of 
California Inc. (2021) 63 Cal.App.5th 660, 662–664 (California 
Medical).)2   
The California Medical Association (CMA) is a nonprofit 
professional organization, founded in 1856, that advocates on 
behalf of California physicians.  By CMA’s count, it has more 
than 37,000 physician members.  CMA’s established mission, 
which it carries out through “ ‘legislative, legal, regulatory, 
economic, and social advocacy’ ” (California Medical, supra, 63 
Cal.App.5th at p. 664), includes “the protection of the public 
health and the betterment of the medical profession.”  According 
to its vice-president and general counsel, CMA “has been 
especially active in advocacy and education on issues involving 
health insurance companies’ interference with the sound 
medical judgment of physicians providing care to enrollees.”   
 
2  
We have drawn some factual background (unchallenged 
by either party through a petition for rehearing) from the 
opinion of the Court of Appeal below.  (See Cal. Rules of Court, 
rule 8.500(c)(2).) 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
4 
In 2010, at least two years before it filed suit, CMA learned 
of Aetna’s Network Intervention Policy from its members and 
became concerned that in threatening termination or actually 
terminating participating physicians for their referrals to 
out-of-network providers, the policy’s implementation interfered 
with physicians’ exercise of their sound medical judgment.  
Aetna maintains that its policy, rather than interfering in 
medical judgments, was designed simply to encourage 
participating physicians, consistent with their judgment, to use 
in-network care providers, such as ambulatory surgery centers, 
and was adopted in part in response to physicians referring 
patients to facilities in which they had financial interests.  The 
merits of the parties’ dispute are not before us, and we express 
no views on them.   
CMA’s general counsel estimated that the organization 
diverted 200–250 hours of staff time to respond to the policy.  
That time was spent on activities including:  (i) “investigat[ion]” 
for the purpose of “advis[ing] physicians and the public 
regarding how to address Aetna’s . . . interference with the 
physician-patient relationship in an effort to avoid litigation 
over this issue”; (ii) “prepar[ing] a 3-page document entitled the 
‘Aetna Termination Resource Guide,’ which [CMA] publicized, 
advising . . . members about Aetna’s new policy . . . , including 
ways to proactively address and counteract Aetna’s policies”; 
(iii) engaging with physicians affected by Aetna’s policy and 
interacting 
with 
Aetna 
on 
physicians’ 
behalf; 
and 
(iv) “prepar[ing] a letter to California’s Department of Insurance 
and California’s Department of Managed Health Care 
requesting that they take action to address” Aetna’s change in 
policy.  According to the general counsel, at least some of this 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
5 
diverted time “would otherwise have been devoted to serving 
[CMA’s] membership” in other respects.  
In July 2012, CMA sued Aetna, alleging Aetna’s 
implementation of the Network Intervention Policy violated the 
UCL both because it was unfairly oppressive and injurious and 
because it violated specified sections of the Insurance Code, 
Business and Professions Code, and Health and Safety Code.  
CMA sought to enjoin Aetna from enforcing the policy.  Aetna 
moved for summary judgment.  It argued that CMA lacked UCL 
standing because CMA had not lost money or property as a 
result of the policy.  Aetna emphasized that the policy applied to 
individual physicians — not to CMA.  CMA countered that it 
had diverted resources in response to the policy.   
The trial court granted Aetna’s motion for summary 
judgment on standing grounds.  Relying on Amalgamated 
Transit, supra, 46 Cal.4th 993, the court concluded that an 
organization’s diversion of resources is not “sufficient to 
establish standing under the UCL.”  CMA appealed.  
The Court of Appeal affirmed.  (California Medical, supra, 
63 Cal.App.5th 660.)  First, the court held that CMA could seek 
an injunction against Aetna only if CMA had individually 
suffered injury in fact and lost money or property; injury to 
CMA’s members did not suffice.  That conclusion is not disputed 
here.  Second, the court addressed whether CMA’s evidence that 
it diverted substantial resources to investigate and oppose 
Aetna’s actions showed that CMA itself suffered injury in fact 
and lost money or property.  (Id. at p. 667.)  The court held that 
the evidence did not create a material dispute of fact on this 
point, because CMA had merely expended resources for its 
members’ benefit:  CMA “was founded to advocate on behalf of 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
6 
its physician members.  The staff time spent here in response to 
Aetna’s termination and threats to terminate physicians was 
typical of the support CMA provides its members in furtherance 
of CMA’s mission.”  (Id. at p. 668.)  If CMA’s expenditure of 
resources in this manner sufficed to establish standing, the 
appellate court reasoned, “then any organization acting 
consistently with its mission to help its members through 
legislative, legal and regulatory advocacy could claim standing 
based on its efforts to address its members’ injuries.  The 2004 
amendments to the UCL eliminated such representational 
standing.”  (California Medical, at p. 668.)   
We granted CMA’s petition for review. 
II.  DISCUSSION 
Sections 17200 to 17210 of the Business and Professions 
Code contain what we now refer to as the unfair competition 
law.  (Stop Youth Addiction, Inc., v. Lucky Stores, Inc. (1998) 17 
Cal.4th 553, 558, fn. 2 (Stop Youth Addiction); see id. at pp. 569–
570 [history of UCL].)  The law’s “purpose ‘is to protect both 
consumers and competitors by promoting fair competition in 
commercial markets for goods and services.’ ”  (McGill v. 
Citibank, N.A. (2017) 2 Cal.5th 945, 954 (McGill).)  To that end, 
the UCL takes aim at “unfair competition,” a term it defines to 
“include any unlawful, unfair or fraudulent business act or 
practice.”  (§ 17200.)  The phrase “any unlawful . . . business act 
or practice” (ibid.) in effect “ ‘ “borrows” ’ rules set out in other 
laws and makes violations of those rules independently 
actionable.”  (Zhang v. Superior Court (2013) 57 Cal.4th 364, 
370.)  The text of section 17200 also “makes clear that a practice 
may be deemed unfair even if not specifically proscribed by some 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
7 
other law.”  (Cel-Tech Communications, Inc. v. Los Angeles 
Cellular Telephone Co. (1999) 20 Cal.4th 163, 180.) 
The UCL’s broad reach contrasts with the somewhat 
limited scope of the remedies that the statutory scheme creates.  
The UCL affords private plaintiffs the ability to seek injunctive 
relief and restitution in response to unfair conduct.  (§ 17203; 
see also Clayworth v. Pfizer, Inc. (2010) 49 Cal.4th 758, 790 
(Clayworth).)  But the UCL does not itself authorize an award 
of damages or attorney’s fees.  (Zhang v. Superior Court, supra, 
57 Cal.4th at p. 371.)  It approves awards of civil penalties only 
in actions brought by specified governmental plaintiffs.  
(§ 17206; State of California v. Altus Finance (2005) 36 Cal.4th 
1284, 1307.)  These limited remedies are not exclusive, however; 
they “are cumulative to each other and to the remedies or 
penalties available under all other laws of this state.”  (§ 17205.)   
This case concerns the circumstances in which a private 
organization may seek injunctive relief under the UCL.  In the 
past, “any person acting for the interests of itself, its members 
or the general public” could bring a UCL action — even if that 
person had not been injured by the business act or practice at 
issue.  (Former § 17204; see Stop Youth Addiction, supra, 17 
Cal.4th at pp. 561, 567.)  Some in the legal and business 
communities were concerned that this broad authority to sue 
allowed attorneys “to file frivolous lawsuits against small 
businesses even though they ha[d] no client or evidence that 
anyone was damaged or misled.”  (Voter Information Guide, 
Gen. Elec. (Nov. 2, 2004) argument in favor of Prop. 64, p. 40; 
see In re Tobacco II Cases (2009) 46 Cal.4th 298, 316–317 
(Tobacco II Cases); Angelucci v. Century Supper Club (2007) 41 
Cal.4th 160, 178, fn. 10.)  In response, the electorate approved 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
8 
Proposition 64, a 2004 initiative measure.  (Californians for 
Disability Rights v. Mervyn’s, LLC (2006) 39 Cal.4th 223, 228–
229 (Mervyn’s); see Voter Information Guide, Gen. Elec., supra, 
text of Prop. 64, § 1, p. 109 [findings and declarations of 
purpose].) 
Proposition 64 limited the set of eligible private UCL 
plaintiffs to those persons who have “suffered injury in fact” and 
“lost money or property as a result of” the business act or 
practice at issue.  (Voter Information Guide, Gen. Elec., supra, 
text of Prop. 64, § 3, p. 109; § 17204.)  The “injury in fact” 
requirement is borrowed from federal constitutional law and 
overlaps to a considerable degree with the “lost money or 
property” inquiry.  (§ 17204; see Kwikset Corp. v. Superior Court 
(2011) 51 Cal.4th 310, 322–323 & fn. 5 (Kwikset).)  The core 
inquiry is whether the plaintiff has suffered “economic 
injury . . . caused by . . . the unfair . . . practice . . . that is the 
gravamen of the claim.”  (Id. at p. 322.) 
Whether CMA has standing to bring a claim under the 
UCL requires us to answer two questions of statutory 
interpretation.3  The first is whether diversion of staff time can 
qualify as an “injury in fact” and loss of “money or property” 
within the meaning of section 17204.  The second is whether an 
organization that chose to divert staff time to counteract the 
defendant’s business practice can be said to have lost that staff 
time “as a result of” (ibid.) that practice.  We review these 
 
3  
That CMA is not a natural person does not matter for 
standing purposes.  Section 17201 defines “person,” as used in 
the UCL’s enforcement provisions, to include “associations and 
other organizations of persons.” 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
9 
interpretive questions de novo, beginning by examining the 
statutory language to determine the voters’ intent.  We construe 
that language in its full statutory context, keeping in mind the 
nature and purposes of the statutory scheme as a whole.  (People 
v. Lewis (2021) 11 Cal.5th 952, 961; Kwikset, supra, 51 Cal.4th 
at p. 321.)  To the extent there are ambiguities in the initiative’s 
language affecting its application to the case, we turn to 
“extrinsic sources such as ballot summaries and arguments for 
insight into the voters’ intent.”  (Kwikset, at p. 321.)  
Whether the trial court erred by granting Aetna’s motion 
for summary judgment is likewise subject to de novo review, and 
like the trial court ruling on the motion, we must view the 
evidence in the light most favorable to CMA and draw all 
reasonable inferences in CMA’s favor.  (Weiss v. People ex rel. 
Department of Transportation (2020) 9 Cal.5th 840, 864; 
Samara v. Matar (2018) 5 Cal.5th 322, 338.)  
A. Economic Injury  
A private plaintiff has UCL standing only if that plaintiff 
“has suffered injury in fact and has lost money or property.”  
(§ 17204.)  Because loss of money or property is a subset of injury 
in fact, proof of harm to money or property will generally satisfy 
the injury-in-fact requirement.  (See Kwikset, supra, 51 Cal.4th 
at pp. 323, 325.)    
The phrase “injury in fact” is borrowed from, and was 
intended to incorporate aspects of, the federal constitutional law 
of standing.  (See Voter Information Guide, Gen. Elec., supra, 
text of Prop. 64, § 1, subd. (e), p. 109 [declaring intent to limit 
standing to plaintiffs who have been “injured in fact under the 
standing requirements of the United States Constitution”].)  To 
establish a case or controversy within the scope of the federal 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
10 
judicial power (U.S. Const., art. III, § 2), a plaintiff in federal 
court “must show (1) an injury in fact, (2) fairly traceable to the 
challenged conduct of the defendant, (3) that is likely to be 
redressed by the requested relief.”  (Federal Election 
Commission v. Cruz (2022) __ U.S. __ [142 S.Ct. 1638, 1646].)  
Proposition 64 incorporated the injury-in-fact requirement into 
the UCL (Kwikset, supra, 51 Cal.4th at pp. 322–323) but did not 
borrow the traceability or redressability requirements of the 
federal standing inquiry.4  To show an injury in fact, a plaintiff 
must identify “ ‘an invasion of a legally protected interest which 
is (a) concrete and particularized, [citations]; and (b) “actual or 
imminent, not ‘conjectural’ or ‘hypothetical.’ ” ’ ”  (Kwikset, at 
p. 322.)   
The UCL’s focus on “los[s]” of “money or property” 
(§ 17204) restricts the broad range of harms that could 
otherwise give rise to standing.  As a matter of federal law, an 
injury can be concrete — i.e., “ ‘real,’ and not ‘abstract’ ” — even 
if the injury is personal instead of economic; even certain 
intangible injuries qualify as injury in fact.  (Spokeo, Inc. v. 
Robins (2016) 578 U.S. 330, 340; accord, TransUnion LLC v. 
Ramirez (2021) __ U.S. __ [141 S.Ct. 2190, 2204]; Kwikset, 
supra, 51 Cal.4th at p. 324, fn. 6.)  Under the UCL, however, 
only injuries to money or property — that is, only economic 
injuries — can support standing.  (Kwikset, at p. 324.)   
 
4  
In place of the federal traceability 
requirement, 
Proposition 64 included its own causation element for standing:  
that the injury was incurred “as a result of” the challenged 
business practice.  (§ 17204.)  We discuss that element in the 
next section. 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
11 
Beyond this limitation to economic injuries, section 
17204’s reference to “money or property” does not otherwise 
define or limit the injury-in-fact inquiry.  (Kwikset, supra, 51 
Cal.4th at pp. 323–325.)  A showing of economic injury requires 
only that the plaintiff allege or prove “a personal, individualized 
loss of money or property in any nontrivial amount.”  (Id. at p. 
325.)  Moreover, because the issue is one of standing, rather 
than the amount of restitution due, “a specific measure of the 
amount of this loss is not required.  It suffices that a plaintiff 
can allege an ‘ “identifiable trifle” ’ [citation] of economic 
injury.”  (Id. at p. 330, fn. 15.)  
As we explained in Kwikset, “[t]here are innumerable 
ways in which economic injury from unfair competition may be 
shown.  A plaintiff may (1) surrender in a transaction more, or 
acquire in a transaction less, than he or she otherwise would 
have; (2) have a present or future property interest diminished; 
(3) be deprived of money or property to which he or she has a 
cognizable claim; or (4) be required to enter into a transaction, 
costing money or property, that would otherwise have been 
unnecessary.  [Citation.]  Neither the text of Proposition 64 nor 
the ballot arguments in support of it purport to define or limit 
the concept of ‘lost money or property,’ nor can or need we supply 
an exhaustive list of the ways in which unfair competition may 
cause economic harm.”  (Kwikset, supra, 51 Cal.4th at p. 323.)   
CMA contends it suffered an economic injury through the 
diversion of personnel and other resources to respond to Aetna’s 
Network Intervention Policy, resources that would otherwise 
have been deployed to assist CMA’s members in other ways.  
Consistent with our observation in Kwikset that Proposition 64 
did not “purport to define or limit” what constitutes lost money 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
12 
or property (Kwikset, supra, 51 Cal.4th at p. 323), we conclude 
that diversion of salaried staff time and other office resources 
can constitute the loss of “money or property” within the 
meaning of section 17204.  Every organization, including CMA, 
has finite resources to devote to its mission.  If the organization 
uses staff time for a particular project, for example, it must 
either pull those hours from a different project or augment its 
staff.  Even if, as here, the personnel involved are paid on a 
salaried basis rather than by the hour, their time clearly holds 
economic value to the organization.  When staff are diverted to 
a new project undertaken in response to an unfair business 
practice, the organization loses the value of their time, which 
otherwise would have been used to benefit the organization in 
other ways.  (Cf. Convoy Co. v. Sperry Rand Corp. (9th Cir. 1982) 
672 F.2d 781, 785–786 [plaintiff in breach of contract case can 
recover cost of salaried staff time spent supervising defective 
computer system]; VMark Software, Inc. v. EMC Corp. (1994) 37 
Mass.App.Ct. 610, 620 [642 N.E.2d. 587, 594] [damages in 
misrepresentation case “should have included the costs of the 
hours fruitlessly spent by EMC employees trying to make the 
defective computer system work”].) 
While the exact question of UCL standing presented here 
is one of first impression in this court, it has been addressed by 
other courts applying California law, and closely analogous 
questions of federal standing have been addressed by the federal 
courts.  Before turning to those decisions, though, we observe 
that CMA’s theory of economic injury is consistent with how we 
have understood this element of UCL standing.  In Kwikset, we 
held that consumers who purchased locksets in reliance on an 
allegedly false “ ‘Made in U.S.A.’ ” label (Kwikset, supra, 51 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
13 
Cal.4th at p. 316) “ha[d] ‘lost money or property’ within the 
meaning of Proposition 64” (id. at p. 317), even though the 
products were not objectively defective and the plaintiffs, “while 
they had spent money, [had] ‘received locksets in return’ ” (id. 
at p. 331).  Consumers deceived in this manner, we explained, 
suffered economic injuries when they purchased products they 
would not have bought, at least at that price, had the products 
been accurately labeled.  (Id. at pp. 329–330.)  Kwikset relied in 
part on our earlier decision in Clayworth, supra, 49 Cal.4th at 
pages 788–789, where we held that the plaintiff pharmacies’ 
ability to pass drug manufacturers’ allegedly illegal overcharges 
on to consumers did not defeat their standing under the UCL, 
because they suffered an economic injury when they paid the 
manufacturers’ inflated prices.  (Kwikset, at p. 334.)   
Our cases thus teach that economic injury for purposes of 
UCL standing, even after Proposition 64, is not limited to 
out-of-pocket expenditures for which no value has been received, 
or to objectively determined overpayments.  In that respect, the 
facts here can be seen as loosely analogous to those in Kwikset 
and Clayworth.  CMA may not have incurred additional 
out-of-pocket costs in responding to Aetna’s allegedly illegal 
practices; its employees were salaried and would have been paid 
regardless.  But the economic value CMA received from their 
labor was reduced.  CMA “lost money or property” (§ 17204) 
when its personnel were diverted from other activities that 
would also have served its goal of assisting its physician 
members.  In Kwikset’s terms, CMA “enter[ed] into a 
transaction, costing money or property, that would otherwise 
have been unnecessary,” as its staff was diverted from what the 
organization regarded as useful projects to respond to Aetna’s 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
14 
allegedly unfair business practices.  (Kwikset, supra, 51 Cal.4th 
at p. 323.)  That injury suffices for standing purposes. 
On facts closer to those shown here, courts have agreed 
that UCL standing can be based on an organization’s diversion 
of resources in response to a threat to its mission.  In Animal 
Legal Defense Fund v. LT Napa Partners LLC (2015) 234 
Cal.App.4th 1270 (Animal Legal Defense), the plaintiff 
organization had advocated for a California ban on the sale of 
foie gras and was active in informing the public about the law 
once enacted.  (Id. at p. 1280.)  On discovering that the 
defendant’s restaurant was continuing to serve foie gras, the 
organization diverted staff time and resources from other 
projects to complete an investigation of the restaurant, share its 
findings with local law enforcement authorities, and try to 
persuade those authorities to enforce the ban against the 
defendant.  (Ibid.)  The Court of Appeal concluded the plaintiff’s 
diversion of resources constituted economic injury as Kwikset 
had explained that UCL standing requirement:  in response to 
the defendant’s allegedly illegal sales, the organization had 
“ ‘enter[ed] into a transaction, costing money or property, that 
would otherwise have been unnecessary.’ ”  (Animal Legal 
Defense, at p. 1280, quoting Kwikset, supra, 51 Cal.4th at 
p. 323.)5 
 
5  
Among the organization’s steps in Animal Legal Defense 
was hiring a private investigator to dine at the restaurant and 
request foie gras.  (Animal Legal Defense, supra, 234 
Cal.App.4th at p. 1275.)  The Court of Appeal’s decision, 
however, does not emphasize that outside expenditure as 
establishing loss of money or property; it places at least equal 
 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
15 
  Similarly, in Southern California Housing Rights Center 
v. Los Feliz Towers Homeowners Ass’n (C.D.Cal. 2005) 426 
F.Supp.2d 1061 (Southern California Housing), a condominium 
owner and a housing rights organization sued a homeowners’ 
association for failing to provide the owner with an accessible 
parking space as a reasonable accommodation for her disability.  
(Id. at p. 1063.)  In a brief analysis, the federal district court 
concluded the organization had standing under the UCL, even 
after Proposition 64, because it had presented “evidence of 
actual injury based on loss of financial resources in investigating 
this claim and diversion of staff time from other cases to 
investigate the allegations here.”  (Id. at p. 1069; accord, In re 
WellPoint, Inc. Out-of-Network UCR Rates Litigation (C.D.Cal. 
2012) 903 F.Supp.2d 880, 900 [relying on Southern California 
Housing in declining to dismiss plaintiff associations’ claims of 
organizational injury].)    
A California appellate court later cited Southern 
California Housing as one of several examples of how 
“expend[ing] money due to the defendant’s acts of unfair 
competition” could establish economic injury, describing the 
federal case with the parenthetical explanation, “housing rights 
center lost financial resources and diverted staff time 
investigating case against defendants.”  (Hall v. Time 
Inc. (2008) 158 Cal.App.4th 847, 854.)  This court, in turn, later 
cited that passage from Hall as “cataloguing some of the various 
forms of economic injury.”  (Kwikset, supra, 51 Cal.4th at p. 323.)  
 
stress on the evidence the organization’s own staff “spent 
months on the effort to persuade Napa authorities to take action 
based on the alleged violations.”  (Id. at p. 1282.)   
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
16 
While Kwikset did not specifically endorse the decision in 
Southern California Housing, our approving citation of Hall’s 
catalogue, which included the citation to Southern California 
Housing and described its diversion-of-resources reasoning, 
indicates at the least that the diversion theory of standing is not 
facially inconsistent with Kwikset’s understanding of the UCL 
after Proposition 64. 
The Court of Appeal below considered Animal Legal 
Defense distinguishable on the ground that the plaintiff 
organization in that case, unlike CMA here, “was not advocating 
on behalf of or providing services to help its members deal with 
their loss of money or property.”  (California Medical, supra, 63 
Cal.App.5th at p. 668.)  Because CMA’s expenditures benefited 
its physician members who were threatened by Aetna’s policy, 
the lower court reasoned, CMA’s suit is in reality a 
representative one.  (Ibid.)  Aetna makes the same argument.   
We find the lower court’s reasoning unpersuasive for at 
least two reasons.  First and most fundamentally, the court’s 
opinion appears to conflate CMA’s own claimed injury, its 
expenditure of resources responding to Aetna’s policy, with the 
injuries to the member physicians affected by that policy.  The 
two injuries are conceptually distinct, even if CMA acted in part 
to prevent further injury to its members.  Relatedly, the Court 
of Appeal appears to have confused associational standing, 
under which an association “may bring an action on behalf of its 
members when the association itself would not otherwise have 
standing” (Amalgamated Transit, supra, 46 Cal.4th at p. 1004), 
with organizational standing, in which the organization asserts 
its own claims based on its own injuries. 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
17 
For the same reason, we are not persuaded that, as Aetna 
maintains, CMA’s standing theory is foreclosed by our decision 
in Amalgamated Transit.  The plaintiff unions in that case, 
unlike CMA, made no claim to injuries distinct from those to 
their members, instead seeking standing only as assignees and 
representatives of the injured union members.  (Amalgamated 
Transit, supra, 46 Cal.4th at pp. 998–999.)  Here, in contrast, 
CMA’s 
standing 
theory — 
organizational 
rather 
than 
associational standing — is based on its own claim of economic 
injury.  
Second, the perceived threat to CMA’s mission went 
beyond injury to physician members of CMA.  By imposing 
unwarranted restrictions on network physicians’ medical 
referrals, in CMA’s view, Aetna’s policy impaired CMA’s efforts 
to protect the public health.  Whether or not the plaintiff 
organization in Animal Legal Defense had members who were 
affected by the alleged unlawful practices, the organization 
could claim injury in its diversion of limited resources to respond 
to a threat to its own mission, a claim that may equally be made 
by a membership organization like CMA. 
The Court of Appeal’s discussion of this point is also 
unclear as to its bearing on the standing question.  Proposition 
64’s amendments to the UCL did not eliminate representative 
actions.  In section 17204, the measure requires that all private 
plaintiffs have suffered an economic injury; in section 17203, it 
mandates that private plaintiffs bringing representative actions 
comply with class actions procedures and requirements 
developed under Code of Civil Procedure section 382.  (See Arias 
v. Superior Court (2009) 46 Cal.4th 969, 977–980.)  Even if 
CMA’s suit were considered a representative one, then, the 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
18 
organization could still claim standing based on its own 
economic injury.6 
Both Animal Legal Defense and Southern California 
Housing relied on a line of federal decisions, beginning with 
Havens Realty Corp. v. Coleman (1982) 455 U.S. 363 (Havens), 
 
6  
As we explained in McGill, supra, 2 Cal.5th at pages 959–
960, a party with individual standing to sue under section 17204 
may do so even if the complaint seeks injunctive relief that 
primarily benefits the public, and such a request for relief does 
not make the action a representative one under section 17203 or 
require compliance with Code of Civil Procedure section 382.   
In its brief, CMA maintains that it seeks injunctive relief 
that would primarily benefit the public rather than CMA’s 
membership and that the action therefore should not be deemed 
representative for purposes of section 17203.  Aetna, on the 
other hand, argues that the action is subject to section 17203, 
and CMA should have to comply with Code of Civil Procedure 
section 382, because the organization’s request for injunctive 
relief primarily seeks to further the interests of its physician 
members.    
We need not resolve this dispute, nor need we address the 
underlying premise that section 17203 might apply to some 
claims of injunctive relief and not others.  (Cf. McGill, at pp. 
960–961 [distinguishing a claim for public injunctive relief from 
a claim seeking “ ‘disgorgement and/or restitution on behalf of 
persons other than or in addition to the plaintiff’ ”].)  The 
question of section 17203’s application, and whether compliance 
with Code of Civil Procedure section 382 is required here, is 
separate from the question of standing under section 17204 — 
the sole ground on which summary judgment against CMA was 
rendered and affirmed.  The Court of Appeal did not address 
section 17203’s requirement of compliance with Code of Civil 
Procedure section 382, but focused throughout on standing 
under section 17204.  We therefore need not decide in this case 
whether CMA’s action is subject to section 17203, and we 
express no opinion on that point.    
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
19 
holding that an organization may establish injury in fact by 
showing that it diverted resources in response to a threat to its 
mission.  (See Animal Legal Defense, supra, 234 Cal.App.4th at 
pp. 1281–1282; Southern California Housing, supra, 426 
F.Supp.2d at p. 1069.)  CMA, as well, relies on Havens and its 
progeny for its standing theory here, while Aetna maintains 
that the narrower standing limits of the UCL after Proposition 
64 make the federal cases inapposite.  On reviewing the federal 
decisions, we find them to be persuasive authority for CMA’s 
theory of UCL standing. 
In Havens, a nonprofit corporation devoted to increasing 
equal housing opportunities in the Richmond, Virginia area 
joined individuals who had allegedly suffered from a building 
owner’s racial steering practices in suing the owner under the 
federal Fair Housing Act of 1968 (Havens, supra, 455 U.S. at pp. 
366–368), alleging the defendant’s practices had frustrated the 
organization’s mission and caused it “ ‘to devote significant 
resources to identify and counteract the defendant’s [sic] racially 
discriminatory steering practices.’ ”  (Id. at p. 379.)  The high 
court held the organization’s allegations satisfied the federal 
Constitution’s injury-in-fact requirement, reasoning that “[i]f, 
as broadly alleged, petitioners’ steering practices have 
perceptibly impaired HOME’s ability to provide counseling and 
referral services for low- and moderate-income homeseekers, 
there can be no question that the organization has suffered 
injury in fact.  Such concrete and demonstrable injury to the 
organization’s activities — with the consequent drain on the 
organization’s resources — constitutes far more than simply a 
setback to the organization’s abstract social interests . . . .”  
(Ibid.)  In a footnote, the court added:  “That the alleged injury 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
20 
results from the organization’s noneconomic interest in 
encouraging open housing does not affect the nature of the 
injury suffered [citation], and accordingly does not deprive the 
organization of standing.”  (Id. at p. 379, fn. 20.) 
Federal courts have applied the reasoning of Havens in 
numerous cases, finding that organizations with a variety of 
missions have suffered injury in fact through the diversion of 
their resources.  (See, e.g., Nnebe v. Daus (2d Cir. 2011) 644 F.3d 
147, 156–157 [taxi drivers’ alliance may base standing to sue 
regulatory agency on expenditure of resources in counseling and 
assisting drivers threatened with summary suspension]; 
Heights Community Congress v. Hilltop Realty, Inc. (6th Cir. 
1985) 774 F.2d 135, 139 & fn. 2 [fair housing organization had 
standing to sue over racial steering]; Crawford v. Marion County 
Election Bd. (7th Cir. 2007) 472 F.3d 949, 951 [Democratic Party 
has standing to challenge voter identification law because the 
law causes the party “to devote resources to getting to the polls 
those of its supporters who would otherwise be discouraged by 
the new law from bothering to vote”]; Fair Housing Council of 
San Fernando Valley v. Roommate.com, LLC (9th Cir. 2012) 666 
F.3d 1216, 1219 [fair housing organizations had standing to sue 
over allegedly illegal roommate referral practices because the 
defendant’s conduct “caused [them] to divert resources 
independent of litigation costs and frustrated their central 
mission”]; El Rescate Legal Services, Inc. v. Executive Office of 
Immigration Review (9th Cir. 1991) 959 F.2d 742, 748 
[organizations 
assisting 
immigrant 
refugees 
established 
standing by alleging that federal agency’s translation policy 
“frustrates [their] goals and requires the organizations to 
expend resources in representing clients they otherwise would 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
21 
spend in other ways”]; Fort Lauderdale Food Not Bombs v. City 
of Fort Lauderdale (11th Cir. 2021) 11 F.4th 1266, 1287 
[organization serving food to homeless had standing to sue city 
over city’s restrictions on food-sharing activities because, among 
other effects, “volunteers who would have normally worked on 
preparing for food-sharing demonstrations had to divert their 
energies to advocacy activities such as attending City meetings 
and organizing protests against the Ordinance”]; Spann v. 
Colonial Village, Inc. (D.C. Cir. 1990) 899 F.2d 24, 27 [fair 
housing organizations had standing to sue over racially biased 
advertising because the allegedly illegal practices caused them 
to “devote resources to checking or neutralizing the ads’ adverse 
impact”]; see also Pacific Legal Foundation v. Goyan (4th Cir. 
1981) 664 F.2d 1221 [adopting diversion-of-resources theory 
prior to Havens].) 
The Havens court did not characterize the alleged injury 
it found sufficient for organizational standing as economic or 
noneconomic; unlike UCL standing, federal constitutional 
standing does not turn on that distinction.  Indeed, the high 
court’s opinion left it somewhat uncertain whether the injury 
that mattered was the “impair[ment to] HOME’s ability to 
provide counseling and referral services for low- and moderate-
income 
homeseekers,” 
the 
“consequent 
drain 
on 
the 
organization’s resources,” or both.  (Havens, supra, 455 U.S. at 
p. 379.)  The footnoted statement that the alleged injury “results 
from the organization’s noneconomic interest in encouraging 
open housing” (id. at p. 379, fn. 20) does not imply that the injury 
itself is noneconomic:  both the “impair[ment]” of the 
organization’s activities (id. at p. 379), seemingly a noneconomic 
harm, and the “consequent drain on the organization’s 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
22 
resources” (ibid.), seemingly an economic one, could be said to 
result from the organization’s interest in promoting equal 
housing opportunities. 
Some of Havens’s progeny, however, have more clearly 
identified the injury that establishes standing under the 
diversion-of-resources theory as an economic one.  In Fair 
Housing of Marin v. Combs (9th Cir. 2002) 285 F.3d 899, 905, 
for example, the court held a fair housing organization suing a 
property owner for racial discrimination “has direct standing to 
sue because it showed a drain on its resources from both a 
diversion of its resources and frustration of its mission.”  The 
appellate court noted that the district court had, in fact, 
awarded more than $16,000 in diversion-of-resources damages 
to compensate the organization for its “ ‘economic losses’ ” in 
staff pay and other “ ‘funds expended.’ ”  (Ibid.; see also Heights 
Community Congress v. Hilltop Realty, Inc., supra, 774 F.2d at 
p. 139, fn. 2 [characterizing housing organization’s expenditures 
for monitoring real estate practices as an “economic injury”].)  In 
Nnebe v. Daus, supra, 644 F.3d at page 157, the court recognized 
that the taxi drivers’ alliance had incurred an “opportunity cost” 
when its resources were diverted to counseling drivers on the 
city’s suspension policy and held that this showing of “economic 
effect” sufficed to establish injury in fact.  And in Crawford v. 
Marion County Election Bd., supra, 472 F.3d at page 951, it was 
the “added cost” that the Democratic Party incurred getting 
voters to the polls that established the party’s standing.  As 
these courts have understood it, at least, the crucial injury in a 
diversion-of-resources case is clearly an economic one. 
Like the courts in Animal Legal Defense and Southern 
California Housing, therefore, we find the Havens line of federal 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
23 
decisions persuasive authority for a rule that an organization’s 
diversion of resources can establish “injury in fact” and “lost 
money or property” for purposes of section 17204.  As explained 
earlier, the voters in Proposition 64 intended to adopt the injury-
in-fact requirement from federal standing law.  The added 
reference to “lost money or property” does no more than limit 
the cognizable injuries to economic ones.  (Kwikset, supra, 51 
Cal.4th at p. 325.)  As Havens and its progeny make clear, an 
organization that has expended staff time or other resources on 
responding to a new threat to its mission, diverting those 
resources from other projects, has suffered an economic injury 
in fact.7 
Relying on the rule that a party opposing summary 
judgment cannot create an issue of fact by a declaration that 
contradicts the party’s prior discovery responses (Shin v. 
Ahn (2007) 42 Cal.4th 482, 500, fn. 12), Aetna argues that the 
declaration by CMA’s general counsel estimating that the 
organization diverted 200–250 hours of staff time to respond to 
 
7  
Aetna cites In re Sony Gaming Networks and Customer 
Data Sec. Breach Litigation (S.D.Cal. 2012) 903 F.Supp.2d 942, 
966, along with two unreported district court rulings, for the 
proposition that loss of time is not an economic loss for purposes 
of UCL standing.  But the plaintiff in each of these cases was an 
individual or a class of individuals who spent their personal, 
uncompensated time responding to the 
alleged unfair 
competition, not an organization alleging diversion of paid staff 
time.  (See id. at p. 950; Knippling v. Saxon Mortg., 
Inc. (E.D.Cal., Mar. 22, 2012, No. 2:11-CV-03116-JAM) 2012 WL 
1142355, p. *1; Ruiz v. Gap, Inc. (N.D.Cal., Feb. 3, 2009, No. 07-
5739 SC) 2009 WL 250481, p. *1.)  Our discussion and holding 
here are limited to organizational standing; we say nothing 
about individual standing.  
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
24 
Aetna’s policy must be disregarded because it contradicts prior 
discovery responses, and that without that declaration there is 
no evidence to show economic injury even under the 
diversion-of-resources theory.  The cited depositions, however, 
show only that one CMA employee (testifying on this point only 
in his individual capacity) was unaware of databases tracking 
expenses “for responding to specific member inquiries” and that, 
according to another employee (whom CMA had designated as 
most qualified to answer), CMA “is working on trying to identify 
the cost for resources expended to address the Aetna illegal 
terminations. . . . [B]ut we don’t have that available today.”  
(Aetna also cites its own response to one of CMA’s filings in 
opposition to summary judgment, but that contains no 
admissions by CMA.)  The cited deposition testimony does not 
contradict the general counsel’s later declaration estimating the 
extent of CMA’s diverted staff time, and accordingly, there is no 
barrier to our consideration of it. 
B. Causation  
A private plaintiff has UCL standing only if the plaintiff 
lost money or property “as a result of” the practice at issue.  
(§ 17204.)  In Kwikset, we concluded this language imposed a 
causation requirement on UCL standing:  “ ‘The phrase “as a 
result of” in its plain and ordinary sense means “caused by” and 
requires a showing of a causal connection or reliance on the 
alleged misrepresentation.’ ”  (Kwikset, supra, 51 Cal.4th at 
p. 326.)  In a fraud case like Kwikset, reliance is key because 
“ ‘reliance is the causal mechanism of fraud.’ ”  (Ibid., quoting 
Tobacco II Cases, supra, 46 Cal.4th at p. 326.)  As in Tobacco II 
Cases, also a fraud case, Kwikset limited its discussion of the 
causation element to such cases, declining to opine on the 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
25 
contours of causation where the alleged unfair competition did 
not lie in misrepresentation.  (Kwikset, supra, 51 Cal.4th at p. 
326, fn. 9; Tobacco II Cases, supra, 46 Cal.4th at p. 325, fn. 17.)  
In the present case, of course, Aetna’s Network Intervention 
Policy is attacked not as fraudulent but as violative of laws 
protecting medical decisionmaking.  Beyond establishing that 
“as a result of” in section 17204 requires a causal connection 
between the alleged unfair competition and the plaintiff’s 
economic injury, therefore, our precedents are of limited use in 
deciding how the statutory requirement is to be applied here. 
Aetna argues that section 17204 imposes a requirement of 
proximate causation akin to that in tort law, and that this 
requirement cannot be met here because CMA independently 
chose to oppose Aetna’s policy.  According to Aetna, “[a] plaintiff 
who chooses to advocate against a practice with which it 
happens to disagree, assuming it lost money at all when 
advocating, did so because of that choice, not because of the 
defendants’ alleged conduct.  [CMA’s] ‘choice,’ in other words, is 
an intervening cause that breaks any chain of causation.”  CMA, 
on the other hand, contends that section 17204 requires only 
“but for” causation.  And even if proximate causation were 
required, CMA further maintains, to break the chain of 
proximate causation an intervening cause must be of 
independent origin, and here the opposite is true.  CMA asserts 
that its “dedication of resources to respond to actions that 
frustrate its mission is not ‘of independent origin’ — the origin 
of the diversion is the allegedly unlawful conduct.”  Because 
CMA’s diversion of resources was a foreseeable response to 
Aetna’s implementation of its policy, CMA argues, it did not 
break the chain of proximate causation.   
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
26 
There are reasons to doubt that section 17204 imports a 
proximate cause requirement from the substantive law of 
negligence into the test for UCL standing.  Neither the text of 
section 17204 nor our decisions in Kwikset and Tobacco II Cases, 
which address reliance as the causative mechanism in 
misrepresentation cases, contain language suggesting a 
proximate causation test applies.  The “unlawful, unfair or 
fraudulent business act[s] or practice[s]” (§ 17200) at which the 
UCL takes aim are not markedly similar to the conduct that can 
give rise to a negligence action.   
Ultimately, however, we need not resolve the question 
here.  In any event, we agree with CMA’s alternative argument:  
CMA’s decision to devote resources to responding to Aetna’s 
Network Intervention Policy was not a supervening or 
superseding cause under the law of proximate causation if it 
were to apply.   
In a decision both parties cite, this court explained that a 
supervening or superseding cause, one that breaks the chain of 
proximate causation, is a “later cause of independent origin” 
that was neither “foreseeable by the defendant” nor “caused 
injury of a type which was foreseeable.”  (Akins v. County of 
Sonoma (1967) 67 Cal.2d 185, 199; accord, Ballard v. 
Uribe (1986) 41 Cal.3d 564, 587; Bigbee v. Pacific Tel. & Tel. 
Co. (1983) 34 Cal.3d 49, 56.)  “ ‘[F]or an intervening act properly 
to be considered a superseding cause, the act must have 
produced “harm of a kind and degree so far beyond the risk the 
original tortfeasor should have foreseen that the law deems it 
unfair to hold him responsible.” ’ ”  (Kahn v. East Side Union 
High School Dist. (2003) 31 Cal.4th 990, 1017.)   
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
27 
The facts here do not involve any such independent and 
unforeseeable conduct by CMA or any third party.  Aetna 
implemented 
its 
Network 
Intervention 
Policy 
by 
communications with physicians in its preferred provider 
networks, in some cases threatening to terminate their network 
participation.  That some of those physicians would alert CMA, 
the state’s most prominent physician association, was highly 
foreseeable.  That CMA would come to their assistance by 
working to reverse or alter Aetna’s policy, attempting to prevent 
its implementation in ways that impinged on its members’ 
medical practices, was equally foreseeable.  CMA’s response to 
Aetna’s policy, while voluntary, thus derived foreseeably from 
Aetna’s conduct.  It was not the type of independent, 
unforeseeable action that would preclude a finding of proximate 
cause in a tort context.  Even if section 17204 incorporated a 
proximate cause requirement into its UCL standing test, that 
requirement would be met. 
Aetna compares this case to Two Jinn, Inc. v. Government 
Payment Service, Inc. (2015) 233 Cal.App.4th 1321, 1326 (Two 
Jinn), in which a licensed bail agency sued an unlicensed 
company for providing bail services in violation of the UCL.  As 
part of its argument for standing, the plaintiff averred it had 
“suffered an economic injury by incurring ‘significant costs and 
expenses’ to investigate the ‘nature, scope and extent of 
Defendant’s conduct.’ ”  (Id. at p. 1334.)8  The Court of Appeal 
 
8  
The plaintiff also claimed injury from direct competition, 
but the appellate court rejected that theory because the evidence 
showed that “any diversion of potential customers from Aladdin 
to GPS results from the Legislature’s establishment of the cash 
 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
28 
rejected that theory of standing on causation grounds:  “These 
‘pre-litigation’ costs do not establish standing to bring a UCL 
claim because they are not an economic injury caused by the 
business practices that Aladdin characterizes as unlawful.  
Rather, . . . the reason Aladdin incurred prelitigation expenses 
was to generate evidence.  Aladdin then used that evidence to 
support this lawsuit.”  (Ibid.)  Distinguishing Havens on its 
facts, the court explained that “[h]ere, proof that Aladdin spent 
money to investigate GPS’s activities would not show that those 
allegedly unfair business activities had any independent 
economic impact on Aladdin’s bail bond business.  Beyond 
that, Havens does not hold or intimate that a party can 
manufacture an economic injury by incurring investigation costs 
to generate evidence for its lawsuit.”  (Id. at p. 1335.)   
Similarly in this case, Aetna argues, its Network 
Intervention Policy did not affect CMA’s operations, since the 
policy applied only to physicians.  CMA should not be able to 
rely on its expenditures opposing that policy for UCL standing, 
any more than the bail agency in Two Jinn, which was not 
directly injured by the defendant’s allegedly illegal conduct, 
could rely on its investigative costs to establish an economic 
injury for standing. 
CMA does not take issue with the propositions, reflected 
in Two Jinn’s reasoning, that the diversion-of-resources theory 
requires a threat to the plaintiff organization’s mission and that 
 
bail payment system as an alternative to the traditional bail 
bond service, and not from the fact that GPS conducts its 
business without a bail agent license.”  (Two Jinn, supra, 233 
Cal.App.4th at p. 1332.) 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
29 
expenditures made for UCL litigation itself cannot support UCL 
standing.  But, CMA argues, both requirements were met here.  
Aetna’s policy, at least in the view of CMA, threatened 
physicians’ medical independence and consequently the public 
health, both objects of CMA’s protective mission.  In response, 
CMA undertook efforts to assist its members in dealing with 
Aetna’s policy, to persuade Aetna to stop enforcing the policy, 
and to spur regulatory action against the policy.  These efforts 
were independent of this litigation, which was commenced 
approximately two years after CMA began responding to 
Aetna’s policy.  
We agree with this analysis.  As the Animal Legal Defense 
court explained, in assessing causation under the diversion-of-
resources theory, “the proper focus is on whether the plaintiff 
‘undertook the expenditures in response to, and to counteract, 
the effects of the defendants’ alleged [misconduct] rather than 
in anticipation of litigation.’ ”  (Animal Legal Defense, supra, 234 
Cal.App.4th at pp. 1283–1284.)  Thus the plaintiff must show 
that the defendant’s actions have posed a threat to the plaintiff 
organization’s mission, causing it to devote resources to allay 
the threat.  (East Bay Sanctuary Covenant v. Biden (9th Cir. 
2021) 993 F.3d 640, 663; Rodriguez v. City of San Jose (2019) 
930 F.3d 1123, 1134 [“The organization cannot, however, 
‘manufacture the injury by . . . simply choosing to spend money 
fixing a problem that otherwise would not affect the 
organization at all’ ”].)9    
 
9  
Although the Proposition 64 voters did not borrow the 
traceability requirement from federal standing law along with 
 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
30 
Moreover, expenditures an organization makes in the 
course of UCL litigation, or to prepare for such litigation, do not 
serve, for purposes of UCL standing, to establish an injury in 
fact resulting from the allegedly unfair competition.  (Buckland 
v. Threshold Enterprises, Ltd. (2007) 155 Cal.App.4th 798, 815.)  
That parallels the rule adopted in several federal decisions 
applying Havens:  “An organization cannot, of course, 
manufacture the injury necessary to maintain a suit from its 
expenditure of resources on that very suit.  Were the rule 
 
that of injury in fact, the closeness of the factual contexts makes 
cases applying Havens somewhat helpful in understanding how 
causation works for organizational standing under section 
17204.  To satisfy the traceability requirement, “there must be 
a causal connection between the injury and the conduct 
complained of — the injury has to be ‘fairly . . . trace[able] to the 
challenged action of the defendant, and not . . . th[e] result [of] 
the independent action of some third party not before the 
court.’ ”  (Lujan v. Defenders of Wildlife (1992) 504 U.S. 555, 
560.)  Where the organization’s mission has been impaired or 
threatened, courts have deemed the diversion of resources 
traceable to the defendant’s conduct.  (See, e.g., Comite de 
Jornaleros de Redondo Beach v. City of Redondo Beach (9th Cir. 
2011) 657 F.3d 936, 943 [organization assisting day laborers 
established sufficient “causal connection” between city’s 
antisoliciting 
ordinance 
and 
organization’s 
diversion 
of 
resources]; Pacific Legal Foundation v. Goyan, supra, 664 F.2d 
at p. 1224 [pre-Havens decision:  in light of the plaintiff’s 
mission, it was “only natural for plaintiff to increase its vigilance 
and efforts” in response to contested policy].)  In some 
circumstances, 
however, 
a 
causal 
chain 
posited 
for 
organizational standing can become so attenuated that it fails 
the fair-traceability test.  (See, e.g., Center for Law and Educ. v. 
Department of Educ. (D.C. Cir. 2005) 396 F.3d 1152, 1160–
1161.)   
 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
31 
otherwise, any litigant could create injury in fact by bringing a 
case, and Article III would present no real limitation.”  (Spann 
v. Colonial Village, Inc., supra, 899 F.2d at p. 27; accord, La 
Asociacion de Trabajadores de Lake Forest v. City of Lake 
Forest (9th Cir. 2010) 624 F.3d 1083, 1088; Fair Housing of 
Marin v. Combs, supra, 285 F.3d at p. 90.) 
As CMA argues, however, it has met both standing 
requirements.  The evidence submitted on summary judgment 
sufficiently showed (that is, it was sufficient to create a triable 
issue) that CMA’s expenditures in diverted resources were 
undertaken in response to a perceived threat to CMA’s ability to 
perform its preexisting mission, which according to its general 
counsel includes “advocacy and education on issues involving 
health insurance companies’ interference with the sound 
medical judgment of physicians.”  CMA alleges that Aetna’s 
policy posed a perceived threat to this mission, in particular to 
the independent medical decisionmaking by its physician 
members and thus to the health of patients; CMA responded by 
diverting its own resources to oppose the policy.  The evidence 
further showed that some or all of those resource diversions 
were independent of any preparations CMA may have made for 
this litigation.  The expenditures included efforts to counsel 
CMA’s members on how to deal with Aetna’s implementation of 
the Network Intervention Policy, provision of public information 
for the use of patients, and interactions with regulatory agencies 
with the goal of stopping Aetna’s policy implementation, or 
alleviating its effects, by means other than private litigation 
under the UCL.  
This is not a case of an organization attempting to 
manufacture standing and insert itself into a dispute in which 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
32 
it had no natural stake.  While voluntary in one sense — CMA, 
like many other organizations, is free to set its own budgetary 
priorities — its decision to expend resources on working to 
counter the perceived threat in Aetna’s policy followed from that 
policy in a sufficiently direct and uninterrupted causal chain.10   
 For the above reasons, Aetna was not entitled to 
summary judgment on causation grounds. 
C.  Evasion of Proposition 64’s Purposes 
Beyond their textual arguments focused on economic 
injury and causation, Aetna and its allied amici curiae contend 
that recognizing a diversion-of-resources theory of standing in 
this case would flout the intent of the voters who passed 
Proposition 64 in order to restrict UCL standing.  To assess 
these claims, we look beyond the operational text in section 
17204 — which is consistent with the diversion-of-resources 
theory but does not explicitly endorse it — and examine other 
indicia of voter intent. 
 
10  
As Aetna notes, one federal appellate court held the 
Havens standing theory inapplicable where the only threat 
posed by a challenged statute was to the plaintiff organization’s 
“pure issue-advocacy.”  (Center for Law and Educ. v. Department 
of Educ., supra, 396 F.3d at p. 1162.)  In a later decision, 
however, the same court expressed doubt about the existence of 
“a sharp distinction between advocacy and other activities” 
(American Soc. for Prevention of Cruelty to Animals v. Feld 
Entertainment, Inc. (D.C. Cir. 2011) 659 F.3d 13, 26) and 
concluded that “[u]ltimately, whether injury to an organization’s 
advocacy supports Havens standing remains an open question” 
(id. at p. 27).  In any event, CMA claims not that Aetna’s policy 
impaired its ability to lobby government agencies on abstract 
issues, but that it threatened CMA’s mission of service to its 
members, the medical profession, and the public health.    
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
33 
In its introductory findings and declarations, Proposition 
64 identified certain assertedly objectionable practices in UCL 
litigation, including the law’s “misuse[] by some private 
attorneys who . . . [¶] . . . [¶] (3) [f]ile lawsuits for clients who 
have not used the defendant’s product or service, viewed the 
defendant’s advertising, or had any other business dealing with 
the defendant.”  (Voter Information Guide, Gen. Elec., supra, 
text of Prop. 64, § 1, subd. (b)(3), p. 109, italics added.)  We 
alluded in Kwikset to this italicized language, describing 
Proposition 64’s “apparent purposes” as eliminating standing 
“for those who have not engaged in any business dealings with 
would-be defendants and thereby strip such unaffected parties 
of the ability to file ‘shakedown lawsuits,’ while preserving for 
actual victims of deception and other acts of unfair competition 
the ability to sue and enjoin such practices.”  (Kwikset, supra, 51 
Cal.4th at p. 317, italics added; see also id. at p. 321.)  Observing 
that CMA neither competes with Aetna nor was itself subject to 
the Network Intervention Policy, Aetna argues CMA had no 
business dealings with it and, therefore, necessarily lacks 
standing to sue under our decision in Kwikset. 
Aetna’s argument reads too much into Kwikset’s allusion 
to Proposition 64’s purposes.  In Kwikset, there was no dispute 
that the plaintiffs had dealt with the defendant, whose allegedly 
false labeling had led the plaintiffs to purchase the defendant’s 
product.  (Kwikset, supra, 51 Cal.4th at p. 319.)  Nowhere in 
Kwikset did we suggest that section 1 of Proposition 64, which 
set out the initiative measure’s findings and statement of 
purpose, holds legal force independent of the actual statutory 
language added by the measure.  With regard to standing, that 
operational language is contained in section 17204, which does 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
34 
not require a plaintiff to have had business dealings with the 
defendant but only to have “suffered injury in fact” and “lost 
money or property as a result of the unfair competition.”  
Kwikset’s holdings were reached through analysis of that 
operative language, not by reliance on the statement of purpose 
in section 1 of Proposition 64.  (See Kwikset, supra, 51 Cal.4th 
at pp. 321–327.)   
Section 1 of Proposition 64 explained to voters why limits 
on standing to sue were viewed as necessary but did not itself 
add any such limits to the law.  The section’s reference to 
plaintiffs who have had no business dealings with the defendant 
formed part of that explanation; it did not add or amend any 
statutory provisions of the UCL.  (See Allergan, Inc. v. Athena 
Cosmetics, 
Inc. 
(Fed.Cir. 
2011) 
640 
F.3d 
1377, 
1383 
[“Proposition 64 did not add a ‘business dealings requirement’ to 
standing under section 17204”].)  Understood as explanatory 
rather than operational, the reference to lack of business 
dealings does not indicate an intent to bar suit by plaintiffs like 
CMA who have suffered economic injury as a result of an 
allegedly unlawful or unfair business practice.   
Though it was neither a competitor of Aetna nor a 
consumer of that company’s services, CMA was affected in its 
mission by Aetna’s policy.  CMA responded by devoting staff 
time and other resources to opposing and helping its members 
navigate that policy’s implementation, a diversion of resources 
that constituted an economic injury.  CMA is far from the type 
of disinterested plaintiff Proposition 64 sought to bar from suing 
under the UCL, and in seeking an injunction against practices 
that caused it to divert its own resources CMA has not brought 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
35 
what the voters characterized as a  “ ‘shakedown lawsuit[].’ ” 
(Kwikset, supra, 51 Cal.4th at p. 317.)    
More broadly, Aetna argues that the diversion-of-
resources theory subverts the limiting intent of Proposition 64 
by allowing an organization to “create standing for [itself] by 
choosing to advocate against any practice the organization 
disagrees with.”  Aetna raises the hypothetical case of an 
organization with a generally stated mission, for example 
“Californians for Fair Competition,” that after “a brief stint of 
advocacy” could have standing for “wide swaths of potential 
UCL litigation,” thus reinstituting the kind of “ ‘shakedown 
suits’ ” by uninjured plaintiffs Proposition 64 was intended to 
foreclose.  Amicus curiae the United States Chamber of 
Commerce makes a similar argument, hypothesizing that “an 
attorney who wishes to sue travel agencies who fail to include 
their agents’ licenses on their websites,” for example, could form 
an 
organization 
with 
a 
stated 
mission 
of 
promoting 
transparency in the travel industry, hire a staff member and, 
“after a few weeks, . . . ‘divert’ that staff member’s time to 
writing letters to travel agencies who have not publicly posted 
their agents’ licenses.”   
We are not persuaded that recognizing a diversion-of-
resources theory in this case will open the door to abuses of the 
sort suggested by Aetna and the amicus curiae.  CMA is an 
organization with a bona fide mission of promoting the medical 
profession and the public health, not one formed for the purpose 
of UCL litigation.  Its pursuit of these goals substantially 
predates the events that gave rise to this litigation, rather than 
being adopted as a pretext to create UCL standing.  Aetna’s 
Network Intervention Policy, in CMA’s view, threatened CMA’s 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
36 
ability to pursue its mission, and it responded by taking several 
steps to oppose the policy and alleviate its effects on CMA’s 
members, independent of any existing or planned UCL 
litigation.  These steps required reallocation of staff time and 
other resources from other ongoing projects, giving rise to the 
economic injury that supports standing here.  CMA presented 
sufficient evidence to, at the least, create triable issues of fact 
on these points.   
In contrast, the organizations in Aetna’s and the amicus 
curiae’s hypotheticals might well have difficulty establishing 
that they were sincerely pursuing missions separate from 
planned UCL litigation and that their efforts on a given issue 
were not undertaken simply to establish standing for such 
litigation.  Without an articulable mission focused enough to 
make sense outside the UCL litigation context, an organization 
like “Californians for Fair Competition” would be hard pressed 
to show that its allocation of resources was in fact undertaken 
in response to a threat to its mission or that it diverted staff 
from mission-oriented work they would otherwise have pursued.  
In short, it is far from clear that an isolated “brief stint of 
advocacy,” unconnected to a preexisting mission independent of 
UCL litigation, would suffice to show economic injury and 
causation for purposes of section 17204.   
III.  CONCLUSION 
Viewing the evidence submitted on Aetna’s motion for 
summary judgment in the light most favorable to CMA and 
drawing all reasonable inferences in CMA’s favor, as we must 
(Weiss v. People ex rel. Department of Transportation, supra, 9 
Cal.5th at p. 864), we conclude the evidence established a triable 
issue of fact as to standing to sue under the UCL.  The Court of 
CALIFORNIA MEDICAL ASSOCIATION v. AETNA HEALTH OF 
CALIFORNIA INC. 
Opinion of the Court by Evans, J. 
 
37 
Appeal erred in affirming the trial court’s grant of summary 
judgment for the defense on the ground that CMA lacked such 
standing. 
IV.  DISPOSITION 
The judgment of the Court of Appeal is reversed.   
 
 
 
 
 
 
 
 
 
 
EVANS, J. 
 
We Concur: 
GUERRERO, C. J. 
CORRIGAN, J. 
LIU, J. 
KRUGER, J. 
GROBAN, J. 
JENKINS, J. 
 
See next page for addresses and telephone numbers for counsel who 
argued in Supreme Court. 
 
Name of Opinion  California Medical Association v. Aetna Health of 
California Inc. 
__________________________________________________________  
 
Procedural Posture (see XX below) 
Original Appeal  
Original Proceeding 
Review Granted (published) XX 63 Cal.App.5th 660 
Review Granted (unpublished)  
Rehearing Granted 
__________________________________________________________  
 
Opinion No. S269212 
Date Filed:  July 17, 2023 
__________________________________________________________  
 
Court:  Superior  
County:  Los Angeles 
Judge:  Elihu M. Berle 
__________________________________________________________   
 
Counsel: 
 
Whatley Kallas, Alan M. Mansfield, Edith M. Kallas, Deborah J. 
Winegard; Altshuler Berzon, Michael Rubin and Stacey M. Leyton for 
Plaintiff and Appellant. 
 
Rob Bonta, Attorney General, Nicklas A. Akers, Assistant Attorney 
General, Michele Van Gelderen and Amy Chmielewski, Deputy 
Attorneys General, for the Attorney General of California as Amicus 
Curiae on behalf of Plaintiff and Appellant. 
 
Strumwasser & Woocher, Michael J. Strumwasser, Bryce A. Gee and 
Salvador Perez for the American Medical Association as Amicus Curiae 
on behalf of Plaintiff and Appellant. 
 
Jerry Flanagan and Ryan Mellino for Consumer Watchdog as Amicus 
Curiae on behalf of Plaintiff and Appellant. 
 
 
 
Law Office of Jonathan Weissglass and Jonathan Weissglass for the 
Service Employees International Union California State Council, 
International Brotherhood of Teamsters Joint Council 7, Writers Guild 
of America, West, Inc., United Food and Commercial Workers Western 
States Council and United Farm Workers of America as Amici Curiae 
on behalf of Plaintiff and Appellant. 
 
Thomas A. Myers, Jonathan M. Eisenberg and Kirra N. Jones for AIDS 
Healthcare Foundation as Amicus Curiae on behalf of Plaintiff and 
Appellant. 
 
David Chiu, City Attorney (San Francisco), Yvonne R. Meré and Owen 
J. Clements, Chief Deputy City Attorneys, Ronald H. Lee, Deputy City 
Attorney, Barbara J. Parker, City Attorney (Oakland), Mara W. Elliott, 
City Attorney (San Diego) and Nora V. Frimann, City Attorney (San 
Jose), for local prosecutors as Amici Curiae on behalf of Plaintiff and 
Appellant. 
 
Cristina Kladis and Christopher Berry for Animal Legal Defense Fund 
as Amicus Curiae on behalf of Plaintiff and Appellant. 
 
Spertus, Landes & Umhofer, Matthew Umhofer, Elizabeth Mitchell; 
Williams & Connolly, Enu Mainigi, Craig Singer, Grant Geyerman and 
Benjamin Hazelwood for Defendant and Respondent. 
 
Munger, Tolles & Olson, Sarah Weiner and Henry Weissmann for 
Chamber of Commerce of the United States of America as Amicus 
Curiae on behalf of Defendant and Respondent. 
 
Daponde Simpson Rowe, Michael J. Daponde and Darcy Muilenburg 
for California Association of Health Plans and Association of California 
Life and Health Insurance Companies as Amici Curiae on behalf of 
Defendant and Respondent. 
 
The Office of Michael Tenenbaum and Michael Tenenbaum for Ken 
Frank and Sean Chaney as Amici Curiae on behalf of Defendant and 
Respondent.
 
 
Counsel who argued in Supreme Court (not intended for 
publication with opinion): 
 
Stacey M. Leyton 
Altshuler Berzon LLP 
177 Post Street, Suite 300 
San Francisco, CA 94108 
(415) 421-7151 ext. 304 
 
Benjamin Hazelwood 
Williams & Connolly LLP 
680 Maine Avenue, SW 
Washington, DC 20024 
(202) 434-5159