United States District Court, C.D. California
ADEL F. SAMAAN, M.D., Plaintiff,
AETNA LIFE INSURANCE COMPANY, et al., Defendants.
FINDINGS OF FACT AND CONCLUSIONS OF LAW RE UNPAID
S. Fischer United States District Judge.
parties agreed to trifurcate this matter. On January 14,
2019, the Court issued an Order re Standing, Exhaustion of
Administrative Remedies, and Contractual Limitations. Dkt.
43. In this second phase, the parties ask the Court to decide
whether Plaintiff is entitled to benefits for certain unpaid
claims. The Court deemed this matter appropriate for decision
without oral argument and took the matter under submission on
August 1, 2019.
reviewed and considered the parties' briefs and the
administrative record, the Court makes the following Findings
of Fact and Conclusions of Law.
is a medical doctor. Dkt. 53-1 (Samaan Dec.) ¶ 1. This
phase involves healthcare services Plaintiff provided to ten
different patients. Dkt. 53-3. The parties agree that each
patient was a beneficiary of the Bank of America Plan (Plan),
as described in the 2013 and 2016 Summary Plan Descriptions,
and that Defendants were the claims administrators of the
Plan. Dkt. 25 (“FAC”) ¶ 5; Dkt. 53 at 2;
Dkt. 60 at 5-6. Plaintiff seeks recovery of unpaid benefits
for 43 claim events involving the patients pursuant to the
Plan. See FAC ¶¶ 40-41; Dkt. 53-3. The
parties agree that the Plan is governed by the Employee
Retirement and Income Security Act of 1974 (ERISA). FAC
¶¶ 40-41; Dkt. 60 at 10.
FINDINGS OF FACT
Terms of the Plan
Plan “applies to current U.S.-based employees” of
Bank of America Corporation. AR 2306 (2013 Plan), 2582 (2016
Plan covers services for “medically necessary care,
” as described in relevant part below:
Unless otherwise noted the Plan cover[s] certain services
and supplies for medically necessary care including:
- Specialty and outpatient care
- Inpatient Services
- Surgical benefits
Id. at 2372 (2013 Plan), 2628 (2016 Plan).
Plan covers certain surgical services, as described in
relevant part below:
Unless otherwise noted, the Plan cover[s] the following
- Surgical benefits cover surgery performed
to treat an illness or injury; medical services by surgeons
[Medical Doctors (MD) or Doctors of Osteopathy (DO)],
assistant surgeons, anesthesiologists, consultants (during
and after an operation and any required second opinions); and
medical services of podiatrists.
- Surgical services include:
o A cutting procedure (except for cutting procedures of the
mouth that are considered dental expenses . . . .)
o Preoperative and postoperative care
Id. at 2374 (2013 Plan).
Plan does not cover services that Defendants deem not
medically necessary, as described in relevant part below:
Unless otherwise noted the Plan do[es] not cover certain
services, procedures and equipment, including:
- Experimental, investigational and unproven
services and procedures; ineffective surgical, medical
psychiatric or dental treatments or procedures; research
studies; or other experimental, investigational or unproven
health care procedures or pharmacological regimes, as
determined by [Defendants], unless approved by [Defendants].
- Services that are not
medically necessary as determined by [Defendants].
Id. at 2379-80 (2013 Plan).
Plan defines “medical necessity” as follows:
Medical necessity or medically necessary refers to services
or supplies provided by hospital, physician, practitioner or
other provider that are determined by [Defendants] to be:
- Consistent with broadly accepted medical
standards in the United States as essential to the evaluation
and treatment of disease or injury and professionally
recognized as effective, appropriate and essential based on
recognized standards of the health care specialty
- Not furnished primarily for the
convenience of the patient, the attending physician or other
- Furnished at the most appropriate level
that can be provided safely and effectively to the patient
- Likely to produce significant positive
outcome, and no more likely to produce negative outcome than
any alternative service or supplies, as it relates to both
the disease or injury involved and your overall health
- Not more costly than an alternative
service or sequence of services at least as likely to produce
equivalent therapeutic or diagnostic results as to the
diagnosis or treatment of that patient's illness, injury
or disease Id. at 2386 (2013 Plan) (internal
footnote omitted), 2659 (2016 Plan).
Pursuant to the Plan, an out-of-network provider may not
recover more than the “reasonable and customary”
fee for a service, as described in relevant part below:
Reasonable and customary (R&C)
Reasonable and customary (R&C) fees are those set each
year by your medical plan as the fees that most doctors in a
geographic area charge for particular services or procedures.
R&C is based on available data resources of competitive
fees in that geographic area.
If your doctor is out-of-network and charges more than the
R&C fee, the Plan will not pay for the amount in excess
of the R&C level. You are responsible for paying this
difference if you are not using an in-network physician.
Id. at 2389 (2013 Plan).
Reasonable and customary - A
reasonable and customary fee is the amount of money that
[Defendant] determines is the normal, or acceptable, range of
payment for specific health-related service or medical
procedure. Reasonable and customary fees operate within given
geographic areas and the exact numbers of such fees depend on
the location of service.
If your doctor is out of network and charges more than the
allowed amount fee, the plan won't pay for any amount
above the allowed amount. You're responsible for paying
this difference which is shown on the explanation of benefits
(E0B) you receive from your medical plan.
Id. at 2620 (2016 Plan).
Plan contains the following clause granting Defendants
discretion in making claims determinations:
The Bank of America Corporation Corporate Benefits Committee,
as plan administrator, has delegated to . . . insurance
companies or other third-party claims administrators
discretionary authority to determine eligibility for benefits
and construe the terms of the applicable component plan and
resolve all questions relating to claims for benefits under
the component plan.
Id. at 2493 (2013 Plan), 2797 (2016 Plan).
The Component Plans that Govern Plaintiff's Claims for
Benefits Are Self-Funded
Plan documents provided by the parties govern multiple
component plans. AR 2306 (2013 Plan), 2582 (2016 Plan).
Defendants are the claims administrators for some, but not
all, of the component plans. Id. at 2496-98 (2013
Plan), 2789-92 (2016 Plan).
Among the component plans for which Defendants are the claims
administrators, some, but not all, provide healthcare
Plaintiff seeks to recover benefits pursuant only to
component plans where both (1) Defendants are the claims
administrators, and (2) the plan provides healthcare
benefits. FAC ¶¶ 39-41. Each of the component plans
that match this description is “[n]ot insured.”
AR 2496 (2013 Plan), 2789 (2016 Plan). The “company and
employees share costs based on actuarial determination,
” and “the employee portion” is pretax.
light of the foregoing, each of the component plans at issue
Plaintiff Adel F. Samaan is a medical doctor practicing in
Los Angeles County, whose primary practice area is
gynecological surgery. Samaan Dec. ¶ 1.
Plaintiff is an out-of-network provider under the Plan. FAC
Dr. James Krominga
James Krominga submitted a declaration in support of
Defendants' claims decisions. Dkt. 60-2 (“Krominga
Dec.”). Dr. Krominga graduated from medical school in
1977, completed a family practice residency in 1980, and
received board certification in family medicine in 1980. Dr.
Krominga's board certification is current. Id.
Krominga has been Defendant Aetna Life Insurance
Company's Senior Medical Director for the Southwest
Markets for the past eight years. Id. ¶ 1. As
Senior Medical Director, he is responsible for oversight of
medical policy implementation, and participates in the
development, implementation, and evaluation of
clinical/medical programs. Id.
Krominga is a fellow of the American Academy of Family
Physicians, and also belongs to the Arizona Academy of Family
Physicians and the Arizona Medical Association. Id.
Assignments of Benefits
Plaintiff states that he “received a written assignment
of benefits in connection with” each of the unpaid
claims at issue. Samaan Dec. ¶ 3.
Plaintiff provided a copy of a written assignment for seven
of the ten patients at issue:
- Patient A, Supplemental Admin. Record
- Patient K, AR at 1495;
- Patient T, id. at 7965, 7966,
- Patient X/AE, id. at 1872;
- Patient Z, id. 1095, 1096; SAR
- Patient AA, AR 726, 727; and
- Patient DD, id. at 1101-03; SAR
Plaintiff did not provide a copy of a written assignment for
the following three patients: Patient LL, Patient AK, Patient
Defendants' Denials of Plaintiff's Claims for
Defendants' Grounds for Denying Plaintiff's
Claims Are Stated in Documents Entitled Explanation of
Benefits and ATV Service Offering Engagements
administrative record contains documents entitled Explanation
of Benefits (EOB) for each of the claim events at issue. The
EOB states Defendants' grounds for denying
Plaintiff's claim. See generally AR.
administrative record contains documents entitled ATV Service
Offering Engagements, which reference many of Plaintiff's
claim events. The ATV Service Offering Engagements provide
further explanation for Defendants' claims
determinations. See generally AR.
Defendants Denied Several of Plaintiff's Claims on
the Grounds that the Services Were Not Performed Based on the
Information Defendants Received
the following 27 claim events, Defendants denied
Plaintiff's claims on the grounds that, “based on
the information received, the services were not
- Patient A (date of service
(“DOS”): 1/3/2015), AR 501;
- Patient A (DOS: 1/19/2015), id.
at 501, 547-48;
- Patient A (DOS: 2/10/2015), id.
- Patient A (DOS: 2/23/2015), id.
- Patient A (DOS: 4/4/2015), id. at
- Patient A (DOS: 7/3/2015), id. at
- Patient A (DOS: 7/6/2015), id. at
- Patient A (DOS: 7/16/2015), id.
- Patient A (DOS: 7/30/2015), id.
- Patient A (DOS: 9/16/2015), id.
- Patient T (DOS: 4/24/2015), id.
- Patient T (DOS: 5/15/1015), id.
- Patient T (DOS: 6/2/2015), id. at
- Patient T (DOS: 11/14/2015), id.
- Patient X/AE (DOS: 3/26/2015),
id. at 1961;
- Patient X/AE (DOS: 4/25/2015),
id. at 1961, 1966;
- Patient X/AE (DOS: 6/26/2015),
id. at 1966-67;
- Patient X/AE (DOS: 7/10/2015),
id. at 2018;
- Patient X/AE (DOS: 7/27/2015),
id. at 8980-81;
- Patient X/AE (DOS: 8/4/2015). id.
- Patient X/AE (DOS: 8/18/2015),
id. at 8356;
- Patient Z (DOS: 8/6/2015), id. at
- Patient Z (DOS: 11/26/2015), id.
- Patient AA (DOS: 10/2/2015), id.
- Patient DD (DOS: 12/8/2015), id.
- Patient DD (DOS: 12/19/2015),
- Patient DD (DOS: 2/13/2016), id.
For Some of the Claim Events, There Is No. Evidence that
Plaintiff Provided Medical Documentation to Defendants
Supporting the Claim During the Claims Administration
ten of the 27 claim events referenced in paragraph 23, there
is no evidence that Plaintiff submitted to Defendants medical
documents supporting the claim during the claims
- Patient A (DOS: 1/3/2015);
- Patient A (DOS: 1/19/2015);
- Patient A (DOS: 2/10/2015);
- Patient A (DOS: 2/23/2015);
- Patient A (DOS: 7/30/2015);
- Patient A (DOS: 9/16/2015);
- Patient T (DOS: 4/24/2015);
- Patient T (DOS: 5/15/1015);
- Patient T (DOS: 6/2/2015); and
- Patient X/AE (DOS: 8/18/2015).
three of these ten claim events, Plaintiff does not cite to
any medical ...