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Wise v. Maximus Federal Services, Inc.

United States District Court, N.D. California, San Jose Division

July 2, 2019

BENJAMIN WISE, Plaintiff,
v.
MAXIMUS FEDERAL SERVICES, INC., et al., Defendants.

          ORDER GRANTING MVI ADMINISTRATORS INSURANCE SOLUTIONS, INC.'S MOTION TO DISMISS WITHOUT PREJUDICE RE: DKT. NO. 55

          LUCY H. KOH, UNITED STATES DISTRICT JUDGE

         Plaintiff Benjamin Wise brings suit against MVI Administrators Insurance Solutions, Inc., Monterey County Hospitality Association Health and Welfare Plan, United HealthCare Services, Inc., Monterey County Hospitality Association, and United HealthCare Insurance Co. (collectively, “Defendants”) with regard to a denial of benefits to which Plaintiff claims he is entitled under his health insurance plan, which is covered by the Employee Retirement Income Security Act (“ERISA”). Before the Court is Defendant MVI Administrators Insurance Solutions, Inc.'s (“MVI” or “Defendant”)[1] motion to dismiss. Having considered the submissions of the parties, the relevant law, and the record in this case, the Court GRANTS Defendant's motion to dismiss without prejudice.

         I. BACKGROUND

         A. Factual Background

         The Court overviews the structure of Plaintiff's insurance plan, then the facts surrounding Plaintiff's allegations.

         1. Plaintiff's Insurance Plan

         Plaintiff's employer, Eric Miller Architects, is a participating employer of the group health and welfare plan (“Plan”) sponsored by the Monterrey County Hospitality Association. ECF No. 1 (“Compl.”) at ¶¶ 34, 36. Plaintiff participates in the Plan through Eric Miller Architects. Id. at ¶ 3. Benefits under the Plan are provided by insurance providers who contract with the Monterey County Hospitality Association Health and Welfare Trust (“Trust”). Id. at ¶ 35. These benefits under the Plan “are subject to the provisions of the Plan, the Trust Agreement, [the] employer's Adoption Agreement, and the determination of the Plan Administrator or health insurance issuer(s).” Id. The Plan Trustees are designated as the Plan Administrator. Id. at ¶ 11. However, the Plan Trustees contracted with MVI “to perform many of the Plan Administrator's tasks.” Id. Moreover, the Summary Plan Description (“SPD”), a document that highlights a Plan participant's “rights and obligations” under the Plan, states that “the use of the term ‘Plan Administrator' in this document refers to MVI.” ECF No. 55-1, Ex. 1 at 1. Thus, Defendant is the designated Plan Administrator.

         The Plan offers health insurance options through United HealthCare Insurance Company (“UHCIC”) and United HealthCare Services, Inc. (“UHC”), which set policies and guidelines regarding the coverage of health benefits. Id. at ¶ 38. “Defendant UHC handles benefit determinations and internal appeals of any benefit denials by the Plan, UHC or UHCIC.” Id. at ¶ 39.

         2. Facts Surrounding Plaintiff's Allegations

         In 2002, Plaintiff was involved in a vehicular accident that rendered Plaintiff's left arm completely paralyzed. Id. at ¶ 4. On July 5, 2017, Dr. Ken Hashimoto assessed Plaintiff and discussed a possible referral for a Myomo prosthetic. Id. at ¶ 21. The Myomo prosthetic, otherwise known as a MyoPro orthosis, is a myoelectric elbow-wrist-hand orthosis manufactured by Myomo, Inc. that could restore functionality to Plaintiff's left arm to assist Plaintiff with daily living activities such as lifting or feeding himself. Id. at ¶¶ 4-5. The MyoPro orthosis works by “sensing a patient's own neurological signals through non-invasive sensors on the arm” to amplify a patient's weak neural signal to help move the limb. Id. at ¶ 25. The MyoPro orthosis has been called “power steering for your arm.” Id. at ¶ 24. Plaintiff claims that he “has tried all available traditional therapies” to restore functionality to his left arm “without success.” Id. at ¶ 20. Thus, Plaintiff asserts that there is “no other option available [to] restore functionality to his arms other than a myoelectric [elbow-wrist-hand] orthosis.” Id.

         Dr. Hashimoto determined that Plaintiff was a candidate for a MyoPro orthosis, and referred Plaintiff to the Valley Institute of Prosthetics and Orthotics for further evaluation by certified prosthetists and orthotists. Id. at ¶¶ 21-22. The Valley Institute of Prosthetics and Orthotics determined that Plaintiff met the criteria to use a myoelectric elbow-wrist-hand orthosis. Id. at ¶ 22. On or about September 19, 2017, Dr. Brandon Green prepared a history and physical exam review of Plaintiff and his condition. Id. at ¶ 40. Dr. Green opined that a myoelectric orthosis is the “best available technology” in helping provide functionality to Plaintiff's left arm. Id. Dr. Green's history and physical exam review formed the basis for Plaintiff's initial request for preauthorization coverage of the MyoPro orthotic made to UHC. Id. at ¶ 41.

         In correspondence dated October 10, 2017, UHC denied Plaintiff's request for coverage of the MyoPro orthotic. Id. at ¶ 42. On November 22, 2017, Dr. Green filed an appeal of UHC's denial of benefits to UHC's Appeals Unit. Id. at ¶ 44. On December 11, 2017, UHC denied Plaintiff's appeal. Id. at ¶ 48. UHC advised Plaintiff that he had exhausted the internal appeal process, and that Plaintiff had the right to an independent medical review through the California Department of Insurance. Id. at ¶ 50. Shortly after the denial of benefits by UHC's Appeals Unit, Plaintiff filed a request for an independent medical review with the California Department of Insurance. Id. at ¶ 52. On January 17, 2018, Dr. Hashimoto completed a “Physician Certification Experimental/Investigational Denials required by the California Department of Insurance” to facilitate an independent medical review. Id. at ¶ 53. On January 26, 2018, Dr. Green submitted extensive information and documentation in support of Plaintiff's independent medical review application. Id. at ¶¶ 54-55. MAXIMUS Federal Services, Inc. (“MAXIMUS”) conducted the independent medical review by three physicians “trained in physical medicine and rehabilitation.” Id. at ¶ 60. Each reviewing physician concluded that “the requested device is not likely to be more beneficial for treatment of the patient's medical condition than any available standard therapy.” Id.

         B. Procedural History

         On December 11, 2018, Plaintiff filed suit against MVI Administrators Insurance Solutions, Inc., Monterey County Hospitality Association Health and Welfare Plan, United HealthCare Services, Inc., Monterey County Hospitality Association, and United HealthCare Insurance Co. ECF No. 1. On April 26, 2019, MVI Administrators Insurance Solutions, Inc. (“Defendant”) filed a motion to dismiss. ECF No. 55 (“Mot.”). On May 10, 2019, Plaintiff filed an opposition. ECF No. 63 (“Opp.”). On May 17, 2019, Defendant filed a reply. ECF No. 77 (“Reply”).

         II. LEGAL STANDARD

         A. Motion to Dismiss under Federal Rule of Civil Procedure 12(b)(6)

         Rule 8(a)(2) of the Federal Rules of Civil Procedure requires a complaint to include “a short and plain statement of the claim showing that the pleader is entitled to relief.” A complaint that fails to meet this standard may be dismissed pursuant to Federal Rule of Civil Procedure 12(b)(6). The U.S. Supreme Court has held that Rule 8(a) requires a plaintiff to plead “enough facts to state a claim to relief that is plausible on its face.” Twombly, 550 U.S. at 570. “A claim has facial plausibility when the plaintiff pleads factual content that allows the court to draw the reasonable inference that the defendant is liable for the misconduct alleged.” Iqbal, 556 U.S. at 678. “The plausibility standard is not akin to a probability requirement, but it asks for more than a sheer possibility that a defendant has acted unlawfully.” Id. (internal quotation marks omitted). For purposes ...


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