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 1 conditions” located in Campbell, California. SAC ¶¶ 1, 8. In March 2018 and July 2018, Plaintiff 2 rendered “medically necessary” “spine surgeries” to three patients—D.B., L.M., and M.B.— 3 whose health insurance benefits were sponsored and administered by Defendant.1 Id. ¶¶ 12, 20, 4 25, 30, 36, 41. All three patients worked for the same employer and were “beneficiar[ies] of a 5 health plan . . . administered” by Defendant. Id. ¶¶ 11, 24, 35. All patients owned an 6 identification card from Defendant that was presented to medical providers in order to obtain 7 medical care. Id. Defendant instructed patients to present an identification card “to assure 8 medical providers that they would be paid for medical care . . . at a percentage of the usual and 9 customary value for such care.” Id. Furthermore, patients’ employer published a summary of the 10 benefits of patients’ medical plans and noted that the plans paid 70% of eligible expenses for care 11 from out-of-network providers.2 Id. ¶¶ 12, 25, 36. …