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Samaan v. Aetna Life Insurance Co.

United States District Court, C.D. California

August 30, 2019

ADEL F. SAMAAN, M.D., Plaintiff,
v.
AETNA LIFE INSURANCE COMPANY, et al., Defendants.

          FINDINGS OF FACT AND CONCLUSIONS OF LAW RE UNPAID CLAIMS

          Dale S. Fischer United States District Judge.

         I. INTRODUCTION

         The 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.

         Having reviewed and considered the parties' briefs and the administrative record, the Court makes the following Findings of Fact and Conclusions of Law.

         II. BACKGROUND

         Plaintiff is a medical doctor. Dkt. 53-1 (Samaan Dec.) ¶ 1. This phase involves healthcare services Plaintiff provided to ten different patients. Dkt. 53-3.[1] 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[2] 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.

         III. FINDINGS OF FACT

         A. Terms of the Plan

         1. The Plan “applies to current U.S.-based employees” of Bank of America Corporation. AR 2306 (2013 Plan), 2582 (2016 Plan).

         2. The 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).

         3. The Plan covers certain surgical services, as described in relevant part below:

Surgical Benefits
Unless otherwise noted, the Plan[] cover[s] the following surgical services:
- 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 Suturing
o Preoperative and postoperative care

Id. at 2374 (2013 Plan).[3]

         4. The 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).[4]

         5. The 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 provider
- 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 condition
- 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).

         6. 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).

         7. The 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).

         B. The Component Plans that Govern Plaintiff's Claims for Benefits Are Self-Funded

         8. The Plan documents provided by the parties govern multiple component plans. AR 2306 (2013 Plan), 2582 (2016 Plan).

         9. Defendants are the claims administrators for some, but not all, of the component plans. Id. at 2496-98 (2013 Plan), 2789-92 (2016 Plan).

         10. Among the component plans for which Defendants are the claims administrators, some, but not all, provide healthcare benefits. Id.[5]

         11. 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. Id.

         12. In light of the foregoing, each of the component plans at issue is self-funded.

         C. Plaintiff

         13. Plaintiff Adel F. Samaan is a medical doctor practicing in Los Angeles County, whose primary practice area is gynecological surgery. Samaan Dec. ¶ 1.

         14. Plaintiff is an out-of-network provider under the Plan. FAC ¶ 11.

         D. Dr. James Krominga

         15. Dr. 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. ¶ 2.

         16. Dr. 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.

         17. Dr. 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.

         E. Assignments of Benefits

         18. Plaintiff states that he “received a written assignment of benefits in connection with” each of the unpaid claims at issue. Samaan Dec. ¶ 3.

         19. Plaintiff provided a copy of a written assignment for seven of the ten patients at issue:

- Patient A, Supplemental Admin. Record (SAR) 50[6];
- Patient K, AR at 1495;
- Patient T, id. at 7965, 7966, 8004;
- Patient X/AE, id. at 1872;
- Patient Z, id. 1095, 1096; SAR 1771;
- Patient AA, AR 726, 727; and
- Patient DD, id. at 1101-03; SAR 222.

         20. Plaintiff did not provide a copy of a written assignment for the following three patients: Patient LL, Patient AK, Patient AR.

         F. Defendants' Denials of Plaintiff's Claims for Benefits[7]

         1) Defendants' Grounds for Denying Plaintiff's Claims Are Stated in Documents Entitled Explanation of Benefits and ATV Service Offering Engagements

         21. The 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.

         22. The 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.

         2) Defendants Denied Several of Plaintiff's Claims on the Grounds that the Services Were Not Performed Based on the Information Defendants Received

         23. For the following 27 claim events, Defendants denied Plaintiff's claims on the grounds that, “based on the information received, the[] services were not provided”:

- 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. at 551;
- Patient A (DOS: 2/23/2015), id. at 554-55;
- Patient A (DOS: 4/4/2015), id. at 570;
- Patient A (DOS: 7/3/2015), id. at 619-20;
- Patient A (DOS: 7/6/2015), id. at 643;
- Patient A (DOS: 7/16/2015), id. at 546;
- Patient A (DOS: 7/30/2015), id. at 676;
- Patient A (DOS: 9/16/2015), id. at 685;
- Patient T (DOS: 4/24/2015), id. at 7282;
- Patient T (DOS: 5/15/1015), id. at 7287;
- Patient T (DOS: 6/2/2015), id. at 7283[8];
- Patient T (DOS: 11/14/2015), id. at 8979;
- 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. at 2065;
- Patient X/AE (DOS: 8/18/2015), id. at 8356;
- Patient Z (DOS: 8/6/2015), id. at 1052;
- Patient Z (DOS: 11/26/2015), id. at 1075;
- Patient AA (DOS: 10/2/2015), id. at 8635;
- Patient DD (DOS: 12/8/2015), id. at 1160;
- Patient DD (DOS: 12/19/2015), id.; and
- Patient DD (DOS: 2/13/2016), id. at 1246.[9]

         a. For Some of the Claim Events, There Is No. Evidence that Plaintiff Provided Medical Documentation to Defendants Supporting the Claim During the Claims Administration Process

         24. For 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 administration process:

- 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).

         25. For three of these ten claim events, Plaintiff does not cite to any medical ...


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