Futterman

I. BACKGROUND

The Plan is a nonprofit health care service plan subject to the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene Act) (§ 1340 et seq.) of which the Parity Act is a part. Under the Knox-Keene Act, a health care service plan “undertakes to arrange for the provision of health care services to subscribers or enrollees, or to pay for or to reimburse any part of the cost for those services, in return for a prepaid or periodic charge paid by or on behalf of the subscribers or enrollees.” (§ 1345, subd. (f )(1), italics added.) Consistent with the provisions of the Knox-Keene Act, the Plan contracts with the Permanente Medical Group (TPMG) in Northern California and Permanente Medical Group in Southern California (SCPMG) to provide health care services to its members. (§ 1345, subd. (f)(1).)

2 The Plan’s health coverage terms are set forth in the members’ “Evidence of Coverage” (EOC). The Plan covers services if several conditions are satisfied, including that the services are “medically necessary”—defined in the EOC as “medically appropriate and required to prevent, diagnose, or treat your condition or clinical symptoms in accord with generally accepted…