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United States District Court for the Northern District of California, San Jose Division
April 8, 2020, Decided; April 8, 2020, Filed
Case No. 18-CV-07454-LHK
[*175] ORDER DENYING PLAINTIFF'S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT UHC'S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT MAXIMUS'S MOTION FOR SUMMARY JUDGMENT
Plaintiff Benjamin Wise brings suit against Defendants United HealthCare Services, Inc. and UnitedHealthCare Insurance Co. (collectively, "UHC"), as well as Defendant MAXIMUS Federal Services, Inc. ("MAXIMUS"), with regard to a denial of benefits to which Plaintiff claims he is entitled under his health insurance plan, which is covered by the [**3] Employee Retirement Income Security Act ("ERISA"). Before the Court are Plaintiff's motion for partial summary judgment, Defendant UHC's motion for summary judgment, and Defendant MAXIMUS's motion for summary judgment.1 Having considered the submissions of the [*176] parties, the relevant law, and the record in this case, the Court DENIES Plaintiff's motion for partial summary judgment; GRANTS in part Defendant UHC's motion for summary judgment; and GRANTS in part Defendant MAXIMUS's motion for summary judgment.
A. Factual Background
The Court overviews the structure of Plaintiff's insurance plan, the nature of independent medical review under California law, and the facts surrounding Plaintiff's allegations.
1. Plaintiff's Insurance Plan
Plaintiff's employer, Eric Miller Architects, participates in the Monterey County Hospitality Association Health & Welfare Plan (the "Plan"). Pursuant to the Plan's Summary Plan Description, "[b]enefits under the Plan are provided by certain insurance providers contracting with the Trust, and are subject to the provisions of the Plan, the Trust Agreement, your employer's Adoption Agreement, and the determination of the Plan Administrator or [**4] health insurance issuer(s)." UHC 108.2 The Plan provides medical benefits through Defendant UHC. UHC 111-12.
Defendant UHC, in turn, promulgates a Certificate of Coverage that "describe[s]  Benefits, as well as  rights and responsibilities, under the Policy." UHC 174. The Certificate of Coverage dictates that Defendant UHC will "pay Benefits for Covered Health Services as described in Section 1: Covered Health Services and in the Schedule of Benefits, unless the service is excluded in Section 2: Exclusions and Limitations." UHC 177. The Certificate of Coverage outlines various "Covered Health Services." UHC 180. In order to qualify as a "Covered Health Service," a treatment or device must be "Medically Necessary." Id. "Medically Necessary" is defined by the Certificate of Coverage as follows:
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445 F. Supp. 3d 170 *; 2020 U.S. Dist. LEXIS 62058 **; 2020 WL 1701758
BENJAMIN WISE, Plaintiff, v. MAXIMUS FEDERAL SERVICES, INC., et al., Defendants.
Prior History: Wise v. Maximus Fed. Servs., 2019 U.S. Dist. LEXIS 110878 (N.D. Cal., July 2, 2019)
Coverage, benefits, fiduciary, medical review, Unproven, instant case, summary judgment, terms, benefit plan, summary judgment motion, therapy, breach of fiduciary duty, documents, reviewers, patients, Experimental, restitution, genuine issue of material fact, clinical evidence, binding, studies, argues, terms of the plan, Third-Party, effective, improper denial, contends, administrative record, medically necessary, health services