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Garcia v. Pacificare of California, Inc.

United States Court of Appeals, Ninth Circuit

May 8, 2014

MARTHA GARCIA, Plaintiff-Appellant,
v.
PACIFICARE OF CALIFORNIA, INC.; UHC OF CALIFORNIA, DBA UnitedHealthcare of California, Defendants-Appellees

Argued and Submitted, October 7, 2013, Pasadena, California

Appeal from the United States District Court for the Central District of California. D.C. No. 8:12-cv-02022-JVS-RNB. James V. Selna, District Judge, Presiding.

Jeffrey Isaac Ehrlich (argued), The Ehrlich Law Firm, Encino, California, for Plaintiff-Appellant.

Ethan P. Schulman (argued), Crowell & Moring, LLP, San Francisco, California; Jennifer S. Romano, Crowell & Moring, LLP, Los Angeles, California, for Defendants-Appellees.

Before: Stephen Reinhardt, Andrew J. Kleinfeld, and Morgan Christen, Circuit Judges. Opinion by Judge Christen.

OPINION

Page 1114

CHRISTEN, Circuit Judge

This case involves a single issue: does an insurance company's categorical exclusion of myoelectric prosthetics from a health insurance plan violate California Health & Safety Code § 1367.18? We have jurisdiction under 28 U.S.C. § 1291 and hold that such an exclusion does not violate this statute.

I. BACKGROUND

In 1989, eleven-year-old Martha Garcia (" Garcia" ) contracted spinal meningitis, which necessitated the amputation of her hands at the wrists and her legs below the knees. From 1990 to 1996 she used body-powered/cable and harness upper-extremity prostheses. When she was a senior in high school she was fitted for myoelectric upper-extremity prostheses.[1] The myoelectric prostheses " allowed [her] to live independently, obtain a college degree, and to work full time."

Since 2006, Garcia has worked for the Regional Center of Orange County (" Regional Center" ). When she began work at the Regional Center, she was included on

Page 1115

her father's Blue Cross health insurance policy that covered myoelectric prostheses. The Regional Center provided health care coverage through PacifiCare,[2] which she selected because it allowed her to receive treatment from the same doctors and prosthetic specialists she had been seeing under her father's Blue Cross policy.

In 2009, Garcia's myoelectric prostheses began to fail, so her physician submitted a replacement request to Memorial Healthcare (" Memorial" ), the independent practice association under contract with PacifiCare for Regional Center employees. Memorial denied the physician's request because " myoelectronic prosthetics are not a benefit covered under [Garcia's] health plan." Garcia appealed the decision to PacifiCare, which upheld the denial of coverage " on the basis of a specific benefit exclusion" per Garcia's Evidence of Coverage document, which states that " myoelectric . . . prosthetics are not covered." PacifiCare does not dispute that Garcia's physician-prescribed myoelectric devices are medically necessary.

In January 2010, Garcia filed a grievance with the California Department of Managed Health Care (" DMHC" ). DMHC determined that it " did not find a violation of the California health plan law regarding this issue." In November 2012, Garcia brought this action in the Central District of California under the Employee Retirement Income Security Act of 1974 (" ERISA" ), 29 U.S.C. § § 1132(a)(1)(B), 1132(a)(3), alleging that PacifiCare's benefit exclusion was contrary to California Health & Safety ...


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