Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Amerine v. DSW, Inc.

United States District Court, C.D. California

April 2, 2018

CHAD AMERINE, an individual, Plaintiff,
v.
DSW, INC.; DSW, INC. BENEFIT PLAN; and DOES 1-10, inclusive; Defendant.

          FINDINGS OF FACT AND CONCLUSIONS OF LAW [30]

          OTIS D. WRIGHT, II UNITED STATES DISTRICT JUDGE.

         I. INTRODUCTION

         Plaintiff Chad Amerine brought this action against DSW, Inc., and DSW, Inc. Benefit Plan (collectively “Defendants”) under the Employee Retirement Income Security Act of 1974 (“ERISA”) to recover damages for the denial of health insurance benefits under a group health insurance plan (the “Plan”) established and funded by Defendants, of which Amerine is a plan participant. He seeks reimbursement for the costs associated with a cochlear implant, which Defendants claim was not medically necessary, under the terms of the Plan.

         On July 10, 2017, after briefing by the parties, the Court ordered that this case would be governed by the abuse of discretion standard of review. (Order, ECF No. 29.)

         On February 5, 2018, the parties simultaneously moved for judgment in advance of the bench trial scheduled for March 13, 2018. (Mot. for Judgment, ECF No. 30; Pl.'s Tr. Brief, ECF No. 31.) After each party filed a responsive brief, and the parties stipulated to the documents comprising the administrative record, the Court issued a Minute Order requesting the parties to respond if they thought oral argument would be productive. (Min. Order, ECF No. 35.) Having heard no response, the Court took the matter under submission on March 8, 2018, and determined the matter suitable for decision without oral argument. Fed.R.Civ.P. 78(b); C.D. Cal. R. 7-15. For the reasons discussed below, the Court concludes Defendants did not abuse their discretion in denying Amerine the benefits he sought, and GRANTS Defendants' Motion. (ECF No. 30.)

         II. FINDINGS OF FACT[1]

         1. Amerine, a California resident, was an employee of DSW, Inc.

         2. The DSW, Inc. Plan is an ERISA employee welfare benefit plan that provides health insurance benefits to DSW's employees. Amerine was covered by the Plan.

         A. The Plan

         3. The Plan is self-funded.

         4. Defendants designated UMR, Inc. (“UMR”), a division of UnitedHealthcare, to provide administrative services, such as processing and adjudicating claims according to the terms of the Plan. (Administrative Record (“AR”) 214; 218-19, ECF No. 32.)

         5. Under the Plan, UMR is named as Third Party Administrator for medical claims.

         6. The Plan reserves “full and discretionary authority” for the Plan Administrator and Third Party Administrator to interpret the plan documents and make benefit determinations. (AR 219.)

         7. The Plan requires that covered services must be “medically necessary.” The Plan defines “medically necessary” as:

health care services provided for the purpose of preventing, evaluating, diagnosing or treating an Illness, Injury, mental illness, substance use disorder, condition, disease or its symptoms, that are all of the following as ...

Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.