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Judith O. Hollinger v. California Physicians' Service D.B.A. Blue Shield of California et al

December 11, 2012

JUDITH O. HOLLINGER, PLAINTIFF,
v.
CALIFORNIA PHYSICIANS' SERVICE D.B.A. BLUE SHIELD OF CALIFORNIA ET AL., DEFENDANTS.



The opinion of the court was delivered by: Ronald S.W. Lew Honorable Ronald S.W. Lew Senior, U.S. District Court Judge

#:1244

STATEMENT OF UNCONTROVERTED FACTS AND CONCLUSIONS OF LAW Re: Defendant California Physicians' Service d.b.a. Blue Shield of California [27] After consideration of Defendant California Physicians' Service d.b.a. Blue Shield of California [27], this Court makes the following findings of fact and conclusions of law:

UNCONTROVERTED FACTS

1. Plaintiff Judith Hollinger ("Plaintiff") is the widow of Dr. Glen Hollinger ("Dr. Hollinger"), who died on August 17, 2010, after battling cancer. Def. Blue Shield's Stmt. of Uncontroverted Facts and Conclusions of Law ("Blue Shield SUF") ¶ 3.

2. Dr. Hollinger was the Chief Medical Officer of Good Samaritan Medical Practice Association, Inc. ("GSMPA"), which is an Independent Physicians Association. Id. ¶ 1.

3. As a physician with Good Samaritan Hospital, Dr. Hollinger received health coverage under a Blue Shield Large Group HMO Plan ("the Plan"). Id. ¶ 2.

4. Dr. Hollinger selected GSMPA as his primary medical group under the Plan. Administrative Record ("AR") at 770.

5. Defendant Advanced Medical Management, Inc. ("AMM") is a medical services organization that provided management and administrative services to Defendant GSMPA. Def. AMM's Stmt. of Uncontroverted Facts and Conclusions of Law ("AMM SUF") ¶ 1.

6. In February 2010, Dr. Hollinger was referred to Excel Diagnostics in Houston, Texas, for cancer treatment involving high dose Indium-III Octreotide therapy. Blue Shield SUF ¶ 12.

7. Excel Diagnostics began administering treatment in March 2010. Id. ¶ 13.

8. Initially, Dr. Hollinger paid in cash for the first round of treatment, but then asked sometime in June 2010 that GSMPA assist him with obtaining approval and payment for subsequent treatment from Blue Shield. Id. ¶¶ 16, 33.

9. Under the Plan, coverage was only available for "medically necessary services," which are defined as:

[T]hose which have been established as safe and effective and are furnished in accordance with generally accepted professional standards to treat an illness, injury, or medical condition, and which, as determined by Blue Shield, are:

(a) consistent with Blue Shield medical policy; and

(b) consistent with the symptoms or diagnosis; and

(c) not furnished primarily for the convenience of the patient, attending Physician or other provider; and,

(d) furnished at the most appropriate level which can be provided safely and effectively to the patient.

Id. ¶ 5.

10. The Plan stated that the medical group or Blue Shield determined whether services are medically necessary. Id. ¶ 6.

11. The Plan did not cover medical services that were "experimental or investigational in nature," which are defined as those treatments "which are not recognized in accordance with generally accepted professional medical standards as being safe and effective for use in the treatment of the illness, injury, or condition at issue." Id. ¶¶ 7-8.

12. The Plan also covered therapy provided as part of a clinical trial for ...


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