California Spine and Neurosurgery Institute v. United Healthcare Insurance Company

I. BACKGROUND

25 A. Factual Background 26 Plaintiff is a “medical facility dedicated to the care and treatment of spine injuries and/or 27 conditions” located in Campbell, California. SAC ¶¶ 1, 8. In March 2018 and July 2018, Plaintiff rendered “medically necessary” “spine surgeries” to three patients—D.B., L.M., and M.B.— whose health insurance benefits were sponsored and administered by Defendant. Id. ¶¶ 12, 20, 25, 30, 36, 41. All three patients worked for the same employer and were “beneficiar[ies] of a health plan . . . administered” by Defendant. Id. ¶¶ 11, 24, 35. All patients owned an identification card from Defendant that was presented to medical providers in order to obtain medical care. Id. Defendant instructed patients to present an identification card “to assure medical providers that they would be paid for medical care . . . at a percentage of the usual and customary value for such care.” Id. Furthermore, patients’ employer published a summary of the benefits of patients’ medical plans and noted that the plans paid 70% of eligible expenses for care from out-of-network providers. Id. ¶¶ 12, 25, 36. …