United States District Court, N.D. California, San Jose Division
ORDER GRANTING MVI ADMINISTRATORS INSURANCE
SOLUTIONS, INC.'S MOTION TO DISMISS WITHOUT PREJUDICE RE:
DKT. NO. 55
H. KOH, UNITED STATES DISTRICT JUDGE
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”) 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.
Court overviews the structure of Plaintiff's insurance
plan, then the facts surrounding Plaintiff's allegations.
Plaintiff's Insurance Plan
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.
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.
Facts Surrounding Plaintiff's Allegations
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.
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 ¶
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.
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
Motion to Dismiss under Federal Rule of Civil Procedure
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 ...