Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-5_17-cv-04260/USCOURTS-cand-5_17-cv-04260-2/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 28:1132 E.R.I.S.A.

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Case No. 17-CV-04260-LHK 

ORDER GRANTING ANTHEM’S MOTION FOR SUMMARY JUDGMENT AND DENYING NATIVIDAD’S 

MOTION FOR SUMMARY JUDGMENT

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United States District Court

Northern District of California

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

SAN JOSE DIVISION

COUNTY OF MONTEREY,

Plaintiff,

v.

BLUE CROSS OF CALIFORNIA, et al.,

Defendants.

Case No. 17-CV-04260-LHK 

Re: Dkt. Nos. 91, 95

Plaintiff County of Monterey dba Natividad Medical Center (“Natividad”) brings the 

instant lawsuit against Defendants Blue Cross of California dba Anthem Blue Cross, and Anthem 

Blue Cross Life and Health Insurance Company (collectively, “Anthem”) for improper denial of 

benefits under 29 U.S.C. § 1132(a)(1)(B). Before the Court is Natividad’s motion for summary 

judgment and Anthem’s motion for summary judgment. Having considered the parties’ briefs, the 

relevant law, and the record in this case, the Court GRANTS Anthem’s motion for summary 

judgment, and the Court DENIES Natividad’s motion for summary judgment.

I. BACKGROUND

A. Factual Background

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ORDER GRANTING ANTHEM’S MOTION FOR SUMMARY JUDGMENT AND DENYING NATIVIDAD’S 

MOTION FOR SUMMARY JUDGMENT

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Natividad is a 172-bed acute care hospital owned and operated by the County of Monterey. 

ECF No. 57 (First Amended Complaint, hereinafter “FAC”) ¶ 3. On or about July 23, 2012,

Anthem and Natividad entered into a Facility Agreement pursuant to which Natividad agreed to 

provide certain healthcare services to Anthem members and Anthem agreed to pay Natividad 

certain rates for those services. ECF No. 95-4 (“Leon Decl.”) ¶ 3. 

The Facility Agreement governs not only claims for Anthem’s insureds, but also services 

claims for members of “Other Payors” for whom Anthem provides claims processing services and 

who have access to Anthem’s network. ECF No. 91 at 4. Natividad alleges that these “Other 

Payors” include 32 ERISA Plans that Natividad has identified in its FAC. FAC ¶¶ 7, 15. The 

FAC alleges that these ERISA Plans entered into contracts with Anthem that required the ERISA 

Plans to comply with the terms of Anthem’s contracts with providers in Anthem’s Managed Care

Network, including the Facility Agreement between Anthem and Natividad. Id. ¶ 18. Natividad 

also alleges that Anthem functions as the de facto plan administrator for the ERISA Plans. Id. ¶ 

10.

At the time Natividad and Anthem entered into the Facility Agreement, Natividad did not 

have its certification to provide trauma services to patients. Leon Decl. ¶ 4. Therefore, the parties 

did not agree on a permanent rate at which Anthem would reimburse Natividad for trauma

services. Id. ¶ 5; ECF No. 94-8 Ex. 1 (“Facility Agreement”) at Plan Compensation Schedule ¶ 

10. Instead, the Facility Agreement contemplated that the parties would negotiate new trauma 

rates once Natividad obtained its certification. Id. On January 5, 2015, Natividad received its 

certification to provide trauma services and began providing trauma services to patients. Leon 

Decl. ¶ 7. In 2014, 2015, and 2016, the parties attempted to negotiate a trauma services rate but 

could not come to an agreement. Id. ¶ 9. In the interim, Anthem interpreted the Facility 

Agreement to apply the emergency services rate contained within the Facility Agreement to the 

trauma claims. Id. ¶ 10. The emergency services rate represents 64.5% of charges, with a cap of 

$5,000 for outpatient services. Id. According to Natividad, “[b]ased on Anthem’s processing of 

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ORDER GRANTING ANTHEM’S MOTION FOR SUMMARY JUDGMENT AND DENYING NATIVIDAD’S 

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the claims and appeals, the self-insured payers that access Anthem’s network, including the 

ERISA plans at issue here, only paid the 64.5% rate to Natividad for inpatient trauma claims, and 

64.5% of charges with a cap of $5,000 for outpatient trauma claims.” Id. ¶ 11. The FAC alleges 

that the total difference between Natividad’s billed charges and the amounts that the ERISA Plans 

are paying for the trauma claims exceeds $18 million. FAC ¶ 29.

Natividad brings the instant claims as an assignee of its patients’ benefits under the ERISA 

Plans. Indeed, because “[a]s a policy, Natividad requires that each patient admitted, including 

ERISA plan members, assigns his or her insurance benefits to Natividad. Each prospective patient 

signs a document entitled Conditions of Admission Financial Agreement. The Conditions of 

Admission form includes a provision in which the patients assign the right to payment of benefits 

to Natividad. Leon Decl. ¶ 16. The assignment of insurance benefits provision states as follows:

I assign and authorize direct payment to the hospital of all insurance benefits payable 

for this hospitalization or for these outpatient services. I agree that the insurance 

company’s payment to the hospital pursuant to this authorization shall discharge the 

insurance company’s obligations to the extent of such payment. I understand that I 

am financially responsible for charges not paid according to this assignment.

ECF No. 92 ¶ 35, Ex. HH; id. ¶ 47, Ex. TT; id. ¶ 39, Ex. LL; id. ¶ 43, Ex. PP; id. ¶ 33, Ex. FF; id.

17, Ex. P; id. ¶ 13, Ex. L. Natividad informed Anthem that Natividad was operating as an 

assignee of the patients because every claim submission to Anthem included a UB-04 form, which 

indicates on Box 54 that the provider, Natividad, had an assignment of benefits from the member. 

Leon Decl. ¶¶ 17–18.

Upon receiving the claim submissions from Natividad, Anthem provided explanations of 

benefit (“EOBs”) that indicated that Anthem priced the claims at the emergency services rate. Id. 

¶¶ 23, 31, 38, 45, 50, 57, 64, 71, 80. The ERISA Plans reimbursed Natividad in accordance with 

the emergency services rate. Id. After Natividad received the improper emergency services rate 

for the trauma claims, Natividad sent Anthem appeal letters. Id. ¶¶ 24–26, 32–33, 39–40, 51–52, 

58–59, 65–66, 72–75, 81–84. Anthem responded to the letters by explaining that the claims were 

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processed correctly in accordance with the Facility Agreement and that the appeal process had 

been exhausted. Id.

In light of the dispute about the appropriate rate included in the Facility Agreement, 

Natividad filed a demand for JAMS arbitration on August 6, 2016. See generally ECF No. 117-4 

(“Demand for Arbitration”). In Natividad’s demand for arbitration, Natividad alleged that Anthem 

violated an implied contract, and Natividad also sought recovery under quantum meruit and a 

declaratory judgment regarding the reasonable value of the trauma services that Natividad 

provided. Id. On August 30, 2018, the arbitrator issued the Final Arbitration Award. ECF No. 

95-1 (“Tooch Decl.”) ¶ 30. In the Final Arbitration Award, the arbitrator concluded that Anthem 

and Natividad did not agree to reimburse Natividad’s trauma claims at the emergency services 

rate. Id. Instead, the arbitrator concluded that the parties impliedly agreed to reimburse Natividad 

for trauma claims at reasonable value, which the arbitrator declared to be 80% of the billed 

charges. Id. Anthem and Natividad have since executed an amendment to the Facility Agreement 

with an effective date of May 1, 2019, which requires Anthem to pay a rate 80% of billed charges 

for trauma claims with a date of service from April 21, 2018 onward. Leon Decl. ¶¶ 12–15.

In its capacity as an assignee of its patients’ benefits, Natividad now asserts one claim 

against Anthem for failure to pay plan benefits under the Employee Retirement Income Security 

Act of 1974 (“ERISA”), 29 U.S.C. § 1132(a)(1)(B). FAC ¶¶ 183–194. Specifically, Natividad 

“believes that ERISA Plans at issue in this case required Anthem and the ERISA Plans to pay 

Natividad customary and reasonable rates for the inpatient and outpatient trauma services that 

Natividad has provided to the ERISA Plan members.” Id. ¶ 192. 

Therefore, Natividad seeks compensatory damages and declaratory relief. Id. at 39. 

Specifically, Natividad seeks a declaration that it is “entitled to be paid a reasonable and 

customary amount for the trauma services it has provided, and is providing to the ERISA Plans,” 

and that Anthem’s “practice of pricing, processing, and paying Natividad’s trauma claims at the 

emergency services rate in the Facility Agreement is improper.” Id.

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B. Procedural History

Natividad filed its initial complaint on July 27, 2017. See ECF No. 1. On November 11, 

2017, the Court stayed the case pending the parties’ arbitration, which concerned breach of 

implied contract and the issue of the reasonable value of trauma services Natividad provided to 

Anthem members. ECF No. 29; FAC ¶¶ 33–35. However, because the arbitration concerned only 

Anthem’s fully-insured members, it did not directly encompass the ERISA Plan claims at issue in 

this litigation. FAC ¶ 34.

On August 10, 2018, the arbitrator issued the Final Arbitration award. Tooch Decl. ¶ 30. 

In the Final Arbitration Award, the arbitrator concluded that Anthem and Natividad did not agree 

to reimburse Natividad’s trauma claims at the emergency services rate. Id. Instead, the arbitrator 

concluded that the parties impliedly agreed to reimburse Natividad for trauma claims at reasonable 

value, which the arbitrator declared to be 80% of the billed charges. Id.

On October 8, 2018, Anthem filed a motion to dismiss the initial complaint. ECF No. 37. 

Natividad opposed on October 22, 2018. ECF No. 41. Anthem replied on October 29, 2018. ECF 

No. 42.

On January 24, 2019, at the initial case management conference, the Court lifted the stay 

and directed the Clerk to reopen the case file. ECF No. 50.

On January 28, 2019, the Court granted Anthem’s motion to dismiss the initial complaint 

without prejudice. ECF No. 52. Specifically, the Court found that Natividad’s complaint failed to 

plead factual allegations with specificity and that factual allegations were missing from the 

complaint, “including the specific claims, dates, explanations of benefits, and the ERISA Plan 

provisions at issue.” Id. at 8. The Court further requested that “the parties meet and confer to 

assess whether claim numbers, patients numbers, or some other claim or patient identifiers could 

be used in public filings that would protect patient privacy, but enable the parties to identify the 

relevant claim or patient without sealing” and that “[u]sing such identifiers would minimize the 

sealing burdens on the parties and the Court in this case.” Id. at 9. The Court also found that 

Natividad’s complaint insufficiently alleged standing and that Natividad needed to allege the 

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specific language of the assignment of benefits. Id. at 9–11. In its motion to dismiss briefing, 

Natividad did not contest its failure and instead argued that it could “easily cure any deficiency by 

quoting the language of its assignment of benefits and/or attaching a sample assignment of 

benefits to any amended complaint.” Id. at 11. Finally, the Court found that Natividad’s 

complaint failed to sufficiently allege that Anthem is a de facto plan administrator because 

Natividad did not specifically identify the ERISA Plans or claims at issue, and thus “the related 

allegations about how Anthem controlled or managed these ERISA Plans [were] necessarily vague 

and conclusory.” Id. at 11–13. The Court granted Natividad leave to amend to cure these 

deficiencies. Id. at 13–14. 

On February 26, 2019, the Court granted the parties’ stipulation to extend Natividad’s 

deadline to file its First Amended Complaint (“FAC”). ECF No. 54. The Court also explained 

that the number of claims and ERISA Plans that Natividad intended to add to the FAC would be 

unmanageable. Id. Thus, the Court required the parties to select ten claims––five chosen by 

Natividad and five chosen by Anthem—to litigate through trial. Id.

On March 13, 2019, Natividad filed its FAC. See FAC. In its FAC, Natividad listed the 

ten claims chosen by the parties (the “Selected Claims”), which consisted of: (1) J.F. Reference 

#45 (Natividad Claim 1); (2) R.G. Reference #49 (Natividad Claim 2); (3) H.L. Reference #75 

(Natividad Claim 3); (4) R.M. Reference #92 (Natividad Claim 4); (5) M.M. Reference #105 

(Natividad Claim 5); (6) B.C. Reference #12 (Anthem Claim 1); (7) A.L. Reference #83 (Anthem 

Claim 2); (8) S.R. Reference #124 (Anthem Claim 3); (9) O.R. Reference #131 (Anthem Claim 4); 

and (10) J.R. Reference #136 (Anthem Claim 5). Id. ¶¶ 44–182. These ten claims involved nine 

different ERISA plans (the “ERISA Plans”).

On March 27, 2019, Anthem filed a motion to dismiss the FAC. See ECF No. 58. On 

April 10, 2019, Natividad opposed. ECF No. 61. Anthem replied on April 17, 2019. ECF No. 

64.

On July 18, 2019, the Court denied Anthem’s motion to dismiss the FAC. ECF No. 81. 

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Specifically, the Court concluded that in the FAC, Natividad adequately alleged that Anthem acted 

as a de facto plan administrator for the relevant nine ERISA plans. Id. at 11. The Court also 

concluded that Natividad adequately alleged that Natividad possessed standing as an assignee for 

the Selected Claims, id. at 17, and that Natividad alleged that it exhausted administrative remedies 

for the Selected Claims, id. at 19.

On October 18, 2019, Anthem filed a motion for summary judgment. ECF No. 91. On 

November 1, 2019, Natividad opposed, ECF No. 118, and on November 8, 2019, Anthem filed a 

reply, ECF No. 129.

On October 18, 2019, Natividad also filed a motion for summary judgment. ECF No. 95. 

On November 1, 2019, Anthem opposed, ECF No. 117, and on November 8, 2019, Natividad filed 

a reply, ECF No. 127. 

On November 1, 2019, Natividad filed a motion to strike the testimony of Anthem’s 

expert, Randall J. Moon. ECF No. 113. On November 15, 2019, Anthem opposed the motion to 

strike, ECF No. 130, and on November 22, 2019, Natividad filed a reply, ECF No. 131.

II. LEGAL STANDARD

Under ERISA § 502, a beneficiary or plan participant may sue in federal court “to recover 

benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or 

to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B); see 

also Aetna Health Inc. v. Davila, 542 U.S. 200, 210 (2004) (“If a participant or beneficiary 

believes that benefits promised to him under the terms of the plan are not provided, he can bring 

suit seeking provision of those benefits.”). A claim of denial of benefits in an ERISA case “is to 

be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary 

discretionary authority to determine eligibility for benefits or to construe the terms of the plan.” 

Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); Montour v. Hartford Life & Acc. 

Ins. Co., 588 F.3d 623, 629 (9th Cir.2009). If the plan confers such discretion, then the denial is 

reviewed for an abuse of discretion. Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 110–11 

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(2008).

“Traditional summary judgment principles have limited application in ERISA cases 

governed by the abuse of discretion standard.” Stephan v. Unum Life Ins. Co. of Am., 697 F.3d 

917, 930 (9th Cir. 2012). Hence, where abuse of discretion is the appropriate standard to review a 

purported denial of benefits, “the usual tests of summary judgment, such as whether a genuine

dispute of material fact exists, do not apply.” Id. (internal quotation marks and citation omitted). 

Instead, the relevant motions for summary judgment merely provide “the conduit to bring the legal 

question before the district court.” Nolan v. Heald College, 551 F.3d 1148, 1154 (9th Cir. 2009) 

(internal quotation marks and citation omitted).

III. DISCUSSION

The instant case involves only a single cause of action: 29 U.S.C. § 1132(a)(1)(B). Under 

29 U.S.C. § 1132(a)(1)(B), Natividad seeks “to recover benefits due to [Natividad]” that are 

allegedly owed pursuant to the terms of at least thirty-two different ERISA plans. Natividad 

asserts that Natividad received the right to bring claims under the ERISA plans through 

assignment from ERISA beneficiaries. In light of the large number of claims involved, the Court 

ordered the parties to select ten different representative claims, which together implicated the 

terms of nine different ERISA plans. FAC ¶¶ 44–182. Natividad has since withdrawn one of the 

selected claims.1 Accordingly, there are now a total of nine claims pending before the Court, 

which together implicate the terms of eight different ERISA plans (the “ERISA Plans”). The 

claims (the “Selected Claims”), and the ERISA Plans they implicate, are listed below:

1. Anthem Claim 5, J.R. Reference # 136 – Western Growers Assurance Trust (“Western 

Growers”);

2. Natividad Claim 5, M.M. Reference # 105 – District Council 16 Health and Welfare 

 

1 ECF No. 95 at 4 n.1 (explaining that as to Anthem’s selected claim, assigned by “A.L.” under the 

Robert F. Kennedy Plan, “[t]his claim does not properly belong in this case, and Natividad 

therefore withdraws it”). On the basis of Natividad’s withdrawal, the Court GRANTS summary 

judgment to Anthem with respect to the claim in question, which is Anthem Claim 2.

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Trust Fund (“District Council 16”);

3. Natividad Claim 3, H.L. Reference # 75 – Bank of the West Medical Plan (“Bank of 

the West”);

4. Natividad Claim 4, R.M. Reference # 92 – Laborers Health and Welfare Trust Fund for 

Northern California (“Laborers”);

5. Anthem Claim 4, O.R. Reference # 131 – Laborers;

6. Natividad Claim 2, R.G. Reference # 49 – IBEW Local 234 Health & Welfare Fund 

(“IBEW”);

7. Natividad Claim 1, J.F. Reference # 45 – Pacific Gas & Electric Health Care Benefits 

Plan (“PG&E”);

8. Anthem Claim 1, B.C. Reference # 12 – Operating Engineers Health & Welfare Trust 

Fund (“Operating Engineers”); and

9. Anthem Claim 3, S.R. Reference # 124 – Delicato Family Vineyards Plan (“Delicato 

Family Vineyards”).

The parties’ cross-motions for summary judgment raise two main questions for the Court’s 

resolution. First, the parties dispute the extent to which Anthem abused its discretion as plan 

administrator in pricing the Selected Claims at the emergency services rate. Natividad maintains 

that the Final Arbitration Award is entitled to collateral estoppel and effectively establishes that 

Anthem abused its discretion. In the alternative, Natividad argues that the Court should 

independently determine that Anthem abused its discretion in interpreting the Facility Agreement 

to apply the emergency services rate to the Selected Claims.

Second, the parties dispute the extent to which Anthem may be named a defendant in the 

instant case to begin with. Anthem maintains that Natividad’s lawsuit is improper for four 

independent reasons: (1) Natividad does not seek to recover ERISA benefits under 29 U.S.C. §

1132(a)(1)(B); (2) Anthem is not a proper defendant under 29 U.S.C. § 1132(a)(1)(B); (3) 

Natividad lacks derivative authority to bring claims under 29 U.S.C. § 1132(a)(1)(B) on behalf of 

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the ERISA beneficiaries; and (4) Natividad failed to exhaust administrative remedies.

The Court ultimately concludes that Natividad’s theory fails with respect to all nine of the 

Selected Claims. The Court reaches this conclusion because even if Anthem could be named as a 

defendant in the instant case, Anthem did not abuse its discretion in interpreting the Facility 

Agreement to apply the emergency services rate to the Selected Claims.

A. Anthem Did Not Abuse Its Discretion in Pricing the Selected Claims at the 

Emergency Services Rate.

Anthem did not abuse its discretion in pricing the Selected Claims at the emergency 

services rate. First, the Final Arbitration Award is not entitled to collateral estoppel on the issue of 

whether Anthem abused its discretion. Second, the Court’s examination of the record establishes 

that Anthem did not abuse its discretion in pricing the Selected Claims at the emergency services 

rate. The Court analyzes each of these two issues in turn.

1. Collateral Estoppel Does Not Resolve the Question of Whether Anthem Abused 

Its Discretion.

Natividad contends that the doctrine of collateral estoppel applies in the instant case. 

According to Natividad, the Final Arbitration Award held that “[t]he parties did not agree that 

Natividad’s claims were to be reimbursed at either the emergency services rate or Other Services 

rate.” ECF No. 95 at 16–17 (quoting Tooch Decl. Ex. 76 (“Final Arbitration Award”) at 15). 

Natividad contends that the Final Arbitration Award resolves the question of whether Anthem 

abused its discretion in the instant case. Anthem disagrees. Anthem argues that because the 

instant case involves federal statutory rights, the arbitration decision is not entitled to collateral 

estoppel. ECF No. 117 at 25. Further, Anthem maintains that the instant case presents ERISArelated issues that were not before the arbitrator. Id. The Court agrees with Anthem. Issue 

preclusion does not resolve the question of whether Anthem abused its discretion.

The Full Faith and Credit Statute, 28 U.S.C. §1738, requires federal courts “to give the 

same ‘full faith and credit’ to the records and judicial proceedings of any state court that they 

would receive in the state from which they arise.” Caldeira v. Cnty. of Kauai, 866 F.2d 1175, 

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1177 (9th Cir. 1989). The Ninth Circuit has explained that a “state court’s confirmation of [an]

arbitration award constitutes a judicial proceeding for purposes of section 1738, and thus must be 

given the full faith and credit it would receive under state law.” Id. at 1178. Here, Natividad 

confirmed the arbitration award in California state court. ECF No. 127 Ex. A. Accordingly, the 

Court must apply the California state law of issue preclusion in order to determine whether the 

arbitration award is entitled to issue preclusion. See Caldeira, 866 F.2d at 1178 (“The state 

court’s confirmation of the arbitration award constitutes a judicial proceeding for purposes of 

section 1738, and thus must be given the full faith and credit it would receive under state law.”).

Under California state law, five threshold requirements must be met before issue 

preclusion applies. “First, the issue sought to be precluded from relitigation must be identical to 

that decided in a former proceeding. Second, this issue must have been actually litigated in the 

former proceeding. Third, it must have been necessarily decided in the former proceeding. 

Fourth, the decision in the former proceeding must be final and on the merits. Finally, the party 

against whom preclusion is sought must be the same as, or in privity with, the party to the former 

proceeding.” Lucido v. Superior Court, 51 Cal.3d 335, 341 (1990). If these threshold 

requirements are met, then the Court must further consider whether the public policy that underlies 

issue preclusion would be advanced by applying issue preclusion to the arbitration decision. In 

other words, as the Supreme Court of California explained, “[t]he public policies underlying 

collateral estoppel—preservation of the integrity of the judicial system, promotion of judicial 

economy, and protection of litigants from harassment by vexatious litigation—strongly influence 

whether its application in a particular circumstance would be fair to the parties and constitute 

sound judicial policy.” Id. at 344; see also In re Kaligh, 338 B.R. 817, 824 (B.A.P. 2006)

(applying California state law on issue preclusion to determine whether arbitration award was 

entitled to issue preclusion). Further, under California law, “preclusion is an affirmative matter 

under which the party asserting preclusion bears the burden of establishing the requirements for its 

imposition.” Id.

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The Court’s issue preclusion analysis quickly comes to an end. This is so because

Natividad does not satisfy the first threshold factor, i.e., whether the issue sought to be precluded 

from relitigation is identical to that decided in a former proceeding. None of the issues that were

decided in the arbitration are “identical” to the issue of whether Anthem abused its discretion in 

interpreting the Facility Agreement. Lucido, 51 Cal.3d at 342.

In Natividad’s demand for arbitration, Natividad alleged that Anthem violated an implied 

contract, and Natividad also sought recovery under quantum meruit and a declaratory judgment 

regarding the reasonable value of the trauma services that Natividad provided. ECF No. 117-4 

(“Demand for Arbitration”). In the Final Arbitration Award, the arbitrator concluded that Anthem 

and Natividad did not agree to reimburse Natividad’s trauma claims at the emergency services 

rate. Tooch Decl ¶ 30. Instead, the arbitrator concluded that the parties impliedly agreed to 

reimburse Natividad for trauma claims at reasonable value, which the arbitrator declared to be 

80% of the billed charges. Id.

Throughout Natividad’s briefing on the instant motions, the precise issue to which 

Natividad seeks to apply the doctrine of issue preclusion is somewhat unclear. However, in 

Natividad’s briefing, Natividad appears to point to two issues that the arbitration decision 

ostensibly resolved, and which Natividad now claims are entitled to preclusive effect. First, 

Natividad asserts that the arbitrator determined that “[t]he parties did not agree that Natividad’s 

claims were to be reimbursed at either the emergency services rate or Other Services rate” in the 

Facility Agreement. ECF No. 95 at 16–17 (internal quotation marks omitted). Second, Natividad

argues that the arbitrator decided “the issue of the reasonable value of Natividad’s trauma 

services.” ECF No. 127 at 15. Neither issue is “identical” to the issue of whether Anthem abused 

its discretion.

First, the fact that the arbitrator ultimately concluded that “[t]he parties did not agree that 

Natividad’s claims were to be reimbursed at either the emergency services rate or Other Services 

rate” in the Facility Agreement is not “identical” to any issue presently before the Court. Here, 

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ORDER GRANTING ANTHEM’S MOTION FOR SUMMARY JUDGMENT AND DENYING NATIVIDAD’S 

MOTION FOR SUMMARY JUDGMENT

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Natividad solely brings a claim for improper denial of benefits under 29 U.S.C. § 1132(a)(1)(B). 

Thus, as Natividad concedes, Natividad’s 29 U.S.C. § 1132(a)(1)(B) claim requires that the Court 

determine whether Anthem abused its discretion in interpreting the Facility Agreement. ECF No. 

95 at 14 (“Where an administrator has discretionary authority to determine ERISA benefits, the 

standard of review in ERISA cases is abuse of discretion.”).

As discussed further infra, in Section III.A.2.a, under the abuse of discretion standard, the 

Court’s analysis is not based on “whose interpretation of the plan documents is most persuasive, 

but whether the [plan administrator’s] interpretation is unreasonable.” Canseco v. Construction 

Laborers Pension Trust for S. Cal., 93 F.3d 600, 606 (9th Cir. 1996) (internal quotation marks and 

citation omitted). Thus, the Ninth Circuit “equate[s] the abuse of discretion standard with 

‘arbitrary and capricious’ review.” Tapley v. Locals 302 and 612 of Intern. Union of Operating 

Engineers-Employers Constr. Indus. Ret. Plan, 728 F.3d 1134, 1139 (9th Cir. 2013). Under this 

approach, an “interpretation of Plan language is entitled to a high level of deference and will not 

be disturbed unless it is ‘not grounded on any reasonable basis.’” Id. (quoting Oster v. Barco of 

Cal. Emps.’ Ret. Plan, 869 F.2d 1215, 1218 (9th Cir. 1988)). Further, Anthem’s “interpretation 

need not be the one this court would have reached but only an interpretation which has rational 

justifications.” O’Rourke v. N. Cal. Elec. Workers Pension Plan, 934 F.3d 993, 1001 (9th Cir. 

2019) (internal quotation marks and citation omitted).

Thus, the determination of whether Anthem abused its discretion in interpreting the 

Facility Agreement is different from whether there was in fact an implied agreement between 

Anthem and Natividad. This difference is critical. Under California law, “[w]hether an issue is 

‘identical’ to a previously adjudicated issue for purposes of collateral estoppel depends on the 

burden and standard of proof applicable in each proceeding or action.” Bennett v. Rancho Cal. 

Water Dist., 35 Cal. App. 5th 908, 919 (2019). Thus, California courts have held that “collateral 

estoppel does not apply where the two proceedings at issue have different burdens of proof or 

where the burden of proof falls on a different party in each proceeding.” People v. Esmaili, 213 

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ORDER GRANTING ANTHEM’S MOTION FOR SUMMARY JUDGMENT AND DENYING NATIVIDAD’S 

MOTION FOR SUMMARY JUDGMENT

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Cal. App. 4th 1449, 1463 (2013). Here, the arbitrator specifically explained that the arbitration 

decision was informed by particular “determinations by the Arbitrator as to credibility and 

relevance, burden of proof considerations, legal principles and the weighing of evidence, both oral 

and written.” ECF No. 94-6 at 2. Indeed, the arbitrator specifically relied on the fact that 

“Anthem [] failed to carry its burden to prove that the expressed intent of both parties was to 

permit it to reimburse Natividad indefinitely for trauma services at the emergency services rate.” 

Id. at 9. As discussed in the foregoing, Anthem does not bear any such burden under 29 U.S.C. § 

1132(a)(1)(B) in the instant case, since Anthem’s interpretation of the Facility Agreement “is 

entitled to a high level of deference and will not be disturbed unless it is ‘not grounded on any

reasonable basis.’” Tapley, 728 F.3d at 1139 (quoting Oster, 869 F.2d at 1218). Hence, under 

California law, the Final Arbitration Award does not resolve the question of whether Anthem 

abused its discretion. See, e.g., In re Sylvia R., 55 Cal. App. 4th 559, 563 (1997) (explaining that 

“the doctrine of collateral estoppel may not apply where two proceedings have differing burdens 

of proof”).

Second, “the issue of the reasonable value of Natividad’s trauma services” is also not 

“identical” to the issue of whether Anthem abused its discretion. ECF No. 127 at 15. Natividad 

contends that the Court may find “that the Facility Agreement contained an open price term,”

which Natividad contends would then require the application of reasonable value under California 

law. ECF No. 95 at 15–16. However, Anthem did not read the Facility Agreement to include an 

open price term. On the contrary, Anthem read the Facility Agreement to apply the emergency 

services rate to the Selected Claims. ECF No. 117 at 23 (“Simply put, the emergency services rate 

applied to trauma services until the parties reached an agreement on a new trauma rate.”). The 

question now before the Court is whether Anthem’s understanding that the emergency services 

rate applied to the Selected Claims constituted abuse of discretion, not whether the Court would 

independently reach a different interpretation of the Facility Agreement. See O’Rourke, 934 F.3d

at 1001 (explaining that the interpretation of an ERISA plan “need not be the one this court would 

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have reached, but only an interpretation which has rational justifications”).

Natividad therefore fails to carry “the burden of establishing the requirements for [claim 

preclusion’s imposition” under California law in the instant case. In re Kaligh, 338 B.R. at 824. 

Accordingly, the Court must independently determine whether Anthem abused its discretion in 

pricing the Selected Claims at the emergency services rate.

2. Anthem Did Not Abuse Its Discretion.

The parties dispute whether Anthem violated 29 U.S.C. § 1132(a)(1)(B) “in applying the 

emergency services rate in the Facility Agreement to price the trauma services Natividad provided 

to the ERISA Plan members.” ECF No. 95 at 15. Natividad contends that Anthem’s 

interpretation of the Facility Agreement to apply the emergency services rate to the Selected 

Claims represented an abuse of discretion under the eight relevant ERISA Plans. Id. at 14. 

Anthem disagrees and maintains that Anthem reasonably believed that “the emergency services 

rate [in the Facility Agreement] applied to trauma services until the parties reached an agreement

on a new trauma rate.” ECF No. 117 at 23.

a. Standard of Review.

In the ordinary course, the Court’s first step in a claim for denial of benefits under ERISA

is to determine whether to apply abuse-of-discretion or de novo review to a plan administrator’s 

denial of benefits. See, e.g., Black v. Greater Bay Bancorp Exec. Supplemental Comp. Benefits 

Plan, No. 16-cv-00486-EDL, 2018 WL 1989494, at *6 (N.D. Cal. Jan. 23, 2018) (explaining that 

in action to recover benefits under 29 U.S.C. § 1132(a)(1)(B), the default standard is de novo, but 

that the standard may shift to abuse of discretion if the plan confers discretion on a plan 

administrator). Here, however, the Court’s task is simple. Both parties agree that abuse of 

discretion constitutes the appropriate standard of review that the Court must apply to review 

Anthem’s actions in pricing the trauma claims. ECF No. 95 at 14 (“Where an administrator has 

discretionary authority to determine ERISA benefits, the standard of review in ERISA cases is 

abuse of discretion.”); ECF No. 117 at 22 (“Anthem did not abuse its discretion in applying the 

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ORDER GRANTING ANTHEM’S MOTION FOR SUMMARY JUDGMENT AND DENYING NATIVIDAD’S 

MOTION FOR SUMMARY JUDGMENT

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emergency services rate in the facility agreement”); see, e.g., Beaston v. Sundt Cos., 804 F. Supp. 

2d 1011, 1016 (D. Ariz. 2011) (Tashima, J.) (“Plaintiff appears to concede that abuse of discretion 

is the proper standard for reviewing her claim that the Committee improperly denied her the right 

to hold her account in Sundt stock until September 30, 2007.”). Accordingly, the Court applies 

the abuse of discretion standard to determine whether Anthem improperly denied benefits under 

29 U.S.C. § 1132(a)(1)(B).

As discussed in the foregoing, under the abuse of discretion standard, the Court’s analysis 

is not based on “whose interpretation of the plan documents is most persuasive, but whether the 

[plan administrator’s] interpretation is unreasonable.” Canseco, 93 F.3d at 606 (internal quotation 

marks and citation omitted). Thus, the Ninth Circuit “equate[s] the abuse of discretion standard 

with ‘arbitrary and capricious’ review.” Tapley, 728 F.3d at 1139. Under this approach, an 

“interpretation of Plan language is entitled to a high level of deference and will not be disturbed 

unless it is ‘not grounded on any reasonable basis.’” Id. (quoting Oster, 869 F.2d at 1218). 

Further, Anthem’s “interpretation need not be the one this court would have reached but only an 

interpretation which has rational justifications.” O’Rourke, 934 F.3d at 1001 (internal quotation 

marks and citation omitted).

A plan administrator abuses its discretion if the plan administrator renders a decision 

without any explanation, improperly construes the terms of the ERISA plan, or relies on a clearly 

erroneous finding of fact. See, e.g., Day v. AT&T Disability Income Plan, 698 F.3d 1091, 1096 

(9th Cir. 2012) (explaining that ERISA plan administrators abuse their discretion if they render 

decisions without any explanation, construe provisions of the plan in a way that conflicts with the 

plain language of the plan, or rely on clearly erroneous findings of fact). The nature of the Court’s

abuse-of-discretion analysis thus depends on the type of error that the plan administrator is alleged 

to have committed. 

Natividad contends that Anthem “relie[d] on clearly erroneous findings of fact” when 

Anthem determined that the Facility Agreement’s emergency services rate applied to Natividad’s 

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trauma claims. ECF No. 95 at 14. The nature of Anthem’s purported “finding of fact” that 

Natividad challenges is unclear. However, Natividad appears to contend that Anthem’s 

determination that the emergency services rate in the Facility Agreement applied to the Selected 

Claims is itself a “clearly erroneous finding[] of fact.” Id. at 15. If Natividad’s framing of the 

issue were correct, then in order to determine whether Anthem abused its discretion, the Court 

would have to examine the record and determine whether the Court was “left with a definite and 

firm conviction that a mistake has been committed,” and the Court would be unable to “merely 

substitute [its] view for that of the fact finder.” Salomaa v. Honda Long Term Disability Plan, 

642 F.3d 666, 676 (9th Cir. 2011) (internal quotation marks and citation omitted).

However, Natividad’s framing of the issue is not correct. The interpretation of an 

agreement allegedly incorporated by an ERISA plan is very different from the type of “findings of 

fact” contemplated by the Ninth Circuit case law in the ERISA context. Such findings of fact 

include determinations of the cause of a claimant’s disability, and whether a particular procedure 

is medically necessary. See, e.g., Boyd v. Bert Bell/Pete Rozelle NFL Players Retirement Plan, 

410 F.3d 1173, 1179 (9th Cir. 2005) (“To hold that the Board abused its discretion, we would have 

to conclude that the entire record leads to a ‘definite and firm conviction that a mistake has been 

committed’ by the Board in concluding that Boyd’s disability did not arise from his football 

career.”); Devers v. Carpenters Health and Welfare Trust Fund for Cal., No. 18-cv-04215-EMC, 

2019 WL 3718596, at *8 (N.D. Cal. Aug. 7, 2019) (“Based on the record, the Trustees' finding 

that Chemet was not a medical necessity was unreasonable whether under de novo or abuse of 

discretion review.”).

By contrast, here, Natividad merely challenges Anthem’s interpretation of the terms of the

Facility Agreement as incorporated by the eight ERISA Plans. Specifically, in the FAC, Natividad 

alleges that Anthem violated ERISA because Anthem underpriced the instant claims in violation 

of the terms of the Facility Agreement, which Natividad argues are incorporated in each of the 

eight ERISA Plans. See FAC ¶¶ 59, 76, 95, 111, 127, 135, 155, 172, 181. Indeed, in Natividad’s 

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motion for summary judgment, Natividad points to specific provisions located within the eight 

relevant ERISA Plan summary plan descriptions, which Natividad argues entitle beneficiaries to 

payment for medical care at the reimbursement rate contemplated by the Facility Agreement. See

ECF No. 95-2 Ex. 52 at 2, 63; id. Ex. 53 at 1; id. Ex. 54 at 12; id. Ex. 55 at 12, 88–89; id. Ex. 57 at 

27, 45, 50; ECF No. 95-3 Ex. 71 ¶¶ 3, 4, Ex. A. at 17, Ex. B at 24, 29; ECF No. 94-5 Ex. 56 at 1–

2; ECF No. 94-6 Ex. 69 ¶ 3, Ex. A at 3, 5–7.

Natividad thus maintains that “each of the eight ERISA plans at issue provide that when a 

beneficiary receives covered treatment at a ‘Participating Provider,’ the amount the ERISA plan

will pay for the treatment (i.e. the benefit under the plan) is determined according to the contract 

between Natividad and Anthem.” ECF No. 127 at 2 (emphasis added). In other words, 

Natividad’s theory is that “[a]ll the ERISA Plans provide that the benefits shall be the rate [sic] in 

the Facility Agreement.” Id. at 3; see, e.g., Lone Star OB/GYN Assocs. v. Aetna Health, 579 F.3d 

525, 530 (5th Cir. 2009) (“The ERISA plans state that Aetna will pay ‘Recognized Charges,’ and, 

under the definition of ‘Recognized Charges,’ state that where Aetna has an agreement with a 

health care provider, the ‘Recognized Charge’ is the rate established in that agreement.”).

The Ninth Circuit has provided a framework for resolving abuse-of-discretion questions

when a plan administrator interprets the terms of an agreement that is incorporated into an ERISA 

plan. Specifically, in Lehman v. Nelson, 862 F.3d 1203 (9th Cir. 2017), the Ninth Circuit 

examined an ERISA plan that allegedly “incorporate[d] provisions from” another agreement into 

the plan. Id. at 1207. The Ninth Circuit deployed the abuse-of-discretion standard to examine the 

interplay between the ERISA plan and the agreement incorporated into that plan. Id. at 1217–18.

In such a situation, the Ninth Circuit indicated that Tapley, 728 F.3d at 1140, provides the relevant 

criteria to determining whether the defendant abused its discretion in interpreting the contested 

terms. 862 F.3d at 1217.

Tapley, 728 F.3d 1134, in turn dictates that there are “three ways in which a Plan 

administrator’s interpretation might” amount to abuse of discretion. O’Rourke, 934 F.3d at 1001. 

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“First, it is an abuse of discretion to ‘construe provisions of a plan in a way that clearly conflicts 

with the plain language of the Plan.’” Id. (quoting Tapley, 728 F.3d at 1140). “Second, it is an 

abuse of discretion to interpret a provision in a way that ‘renders nugatory other provisions of the

Plan.’” O’Rourke, 934 F.3d at 1001 (quoting Tapley, 728 F.3d at 1140). “Third, it is an abuse of 

discretion to give an interpretation that ‘lacks any rational nexus to the primary purpose of the 

Plan.’” O’Rourke, 934 F.3d at 1001 (quoting Tapley, 728 F.3d at 1140).

The Court proceeds to apply this framework to Anthem’s interpretation of the Facility 

Agreement in the instant case, mindful that the abuse of discretion standard is inherently flexible

and “allows a court to tailor its review to all the circumstances before it.” Abatie v. Alta Health & 

Life Ins. Co., 458 F.3d 955, 968 (9th Cir. 2006).

b. Application of Standard of Review to the Instant Case.

In the instant case, Natividad argues that Anthem abused its discretion when Anthem 

interpreted the Facility Agreement to apply the emergency services rate to the Selected Claims. 

Indeed, Natividad argues that “at the time the[] claims were paid, there was no trauma rate in the 

Facility Agreement.” ECF No. 95 at 15. Anthem counters that Anthem reasonably understood the 

Facility Agreement to dictate that “the emergency services rate applied to trauma services until the 

parties reached an agreement on a new trauma rate,” and that this interpretation did not amount to 

abuse of discretion. ECF No. 117 at 23. The Court agrees with Anthem. Anthem did not abuse 

its discretion as plan administrator in interpreting the emergency services rate to apply to the 

Selected Claims.

“Traditional summary judgment principles have limited application in ERISA cases 

governed by the abuse of discretion standard.” Stephan v. Unum Life Ins. Co. of Am., 697 F.3d 

917, 930 (9th Cir. 2012). Hence, because the parties agree that abuse of discretion is the 

appropriate standard for the Court to apply here, “the usual tests of summary judgment, such as 

whether a genuine dispute of material fact exists, do not apply.” Id. (internal quotation marks and 

citation omitted). Instead, the instant motions for summary judgment merely provide “the conduit 

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to bring the legal question before the district court.” Nolan v. Heald College, 551 F.3d 1148, 1154 

(9th Cir. 2009) (internal quotation marks and citation omitted). Natividad does not argue that any 

conflict of interest or procedural irregularity on the part of Anthem must be factored into the 

Court’s abuse-of-discretion analysis.

2

 Accordingly, Anthem’s interpretation of the Facility 

Agreement is generally entitled to “broad deference.” O’Rourke, 934 F.3d at 998 (internal 

quotation marks and citation omitted).

Nevertheless, the Court’s review is not toothless. The Court must still “closely read[] 

contested terms” and analyze them under traditional contract principles in order to determine 

whether Anthem’s interpretation was reasonable. Tapley, 728 F.3d at 1140. As discussed in the 

foregoing, under Ninth Circuit precedent, there are three ways in which a plan administrator’s 

interpretation of provisions of an ERISA plan may constitute an abuse of discretion. “First, it is an 

abuse of discretion to ‘construe provisions of a plan in a way that clearly conflicts with the plain 

language of the Plan.’” O’Rourke, 934 F.3d at 1001 (quoting Tapley, 728 F.3d at 1140). “Second, 

it is an abuse of discretion to interpret a provision in a way that ‘renders nugatory other provisions 

of the Plan.’” O’Rourke, 934 F.3d at 1001 (quoting Tapley, 728 F.3d at 1140). “Third, it is an 

abuse of discretion to give an interpretation that ‘lacks any rational nexus to the primary purpose 

of the Plan.’” O’Rourke, 934 F.3d at 1001 (quoting Tapley, 728 F.3d at 1140). The Court 

considers these possibilities in turn, as applied to Anthem’s reading of the Facility Agreement.

First, Natividad contends that Anthem’s decision to reimburse the Selected Claims at the 

emergency services rate clearly conflicted with the plain language of the Facility Agreement. 

Specifically, Natividad argues that “[a] simple reading of the Facility Agreement reveals that it did 

 

2

In its exhaustion of administrative remedies argument, Natividad generically asserts that Anthem 

failed to follow the requirements of 29 C.F.R. § 2560.503-1(g). ECF No. 95 at 22. Natividad 

does not assert such a failure in its discussion of whether Anthem abused its discretion. Moreover, 

these alleged failures were “minor irregularit[ies]” that do not affect the “broad deference” owed 

to Anthem. Abatie, 458 F.3d at 973 (explaining that “minor irregularit[ies]” do not affect “broad 

deference” owed to plan administrators). This is particularly so in light of the fact that the record 

demonstrates that Natividad was well aware of Anthem’s interpretation of the Facility Agreement.

See ECF No. 117-4 (“Demand for Arbitration”) ¶ 9 (“Anthem is currently paying the emergency 

rate for trauma claims . . . .”).

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not contain a trauma rate.” ECF No. 95 at 15. Not so. In the Facility Agreement, the “parties 

acknowledge that currently Facility [i.e., Natividad] is not certified to provide trauma services and 

that all such services are currently reimbursable under the emergency services rate.” ECF No. 

94-8 Ex. 1 (“Facility Agreement”) at Plan Compensation Schedule ¶ 10 (emphasis added). While

the Facility Agreement did not use the precise phrase “trauma rate” in the foregoing sentence, the 

Facility Agreement does appear to contemplate that the emergency services rate would comprise 

the rate at which trauma claims would be reimbursed until the parties agreed to another rate. 

Further, the Facility Agreement specifically indicates that the “new trauma reimbursement rate 

shall be applied prospectively. Facility [i.e., Natividad] acknowledges that Anthem shall have no 

obligation to retroactively adjust Claims notwithstanding that Facility [i.e., Natividad] may have 

had such trauma certification in place and able [sic] to perform trauma services prior to the 

effective date of the new trauma reimbursement rate.” Id. Thus, the Facility Agreement 

specifically contemplates the possibility that Natividad would receive the trauma certification but 

that some time would pass before the parties could agree to a “new trauma reimbursement rate.” 

This is of course precisely what occurred in the instant case.

In that event, between Natividad’s receipt of the trauma certification and “the effective 

date of the new trauma reimbursement rate,” the plain language of the Facility Agreement

suggests the continued application of the emergency services rate. This is so because, by its plain 

language, the Facility Agreement specifically indicates that “such new trauma reimbursement rate 

will replace the emergency services rate for such trauma services.” Id. The logical interpretation 

of the foregoing language is that the emergency services rate constitutes the trauma reimbursement 

rate until the time that the parties adopt a new trauma reimbursement rate, at which point the 

emergency services rate would be “replace[d].” Id. There is no gap between the application of the 

emergency services rate and the new trauma reimbursement rate. Thus, the plain language appears 

to support Anthem’s reading of the Facility Agreement: the emergency services rate applies to 

trauma claims, like the Selected Claims, until a new rate is established.

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Second, Natividad does not point to any provisions of the Facility Agreement or the

ERISA Plans that were rendered nugatory by Anthem’s interpretation. By contrast, Natividad’s 

interpretation of the Facility Agreement renders certain language nugatory. For instance, 

Natividad contends that the Facility Agreement only “stated that the parties would negotiate 

trauma rates after the hospital received its certification.” ECF No. 95 at 15. If this interpretation 

is correct, then Natividad’s reading appears to eliminate the Facility Agreement’s statement that 

“all such services are currently reimbursable under the emergency services rate.” Facility 

Agreement at Plan Compensation Schedule ¶ 10. Moreover, Natividad’s claim that the Facility 

Agreement “did not contain a trauma rate” renders the Facility Agreement’s repeated references to 

“a new trauma reimbursement rate” following Natividad’s trauma certification confusing. Id.

(emphasis added). If Natividad’s interpretation were correct, there would have been no need for 

the Facility Agreement to use the “new” modifier to specify the trauma rate that the parties would 

eventually adopt following Natividad’s trauma certification.

Third, and finally, Anthem’s interpretation did not “lack any rational nexus to the primary 

purpose of” the ERISA Plans. Tapley, 728 F.3d at 1140. The ERISA Plans themselves only 

vaguely incorporate the reimbursement rates by reference. See, e.g., ECF No. 95-2 Ex. 54 at 12

(Western Growers SPD dictating that “Covered Expense for a Participating Provider is based upon 

the Negotiated Contract Rate”). Thus, as Anthem notes, the question of the correct trauma 

reimbursement rate within the Facility Agreement mostly amounts to a “provider payment 

dispute” that arises almost entirely from the contractual relationship between Anthem and 

Natividad, not from the terms of the ERISA Plans themselves. ECF No. 117 at 12. Further, 

Anthem produced testimony from multiple witnesses associated with the ERISA Plans in which 

the witnesses could not identify any situations in which ERISA Plan beneficiaries would even be 

aware of the applicable reimbursement rates for providers, much less challenge them. See ECF 

No. 117-2 Ex. A (“King Depo.”) at 72:9–11 (Q: “Is there a scenario where a member would 

appeal pricing?” A: “Not that I can think of.”); id. Ex. B (“Chapman Depo.”) at 50:14–15 (“[T]he 

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ORDER GRANTING ANTHEM’S MOTION FOR SUMMARY JUDGMENT AND DENYING NATIVIDAD’S 

MOTION FOR SUMMARY JUDGMENT

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pricing of the claim is per the agreement between Anthem and the provider.”).

“In sum, none of the three situations [the Ninth Circuit] identified in Tapley are present 

here.” O’Rourke, 934 F.3d at 1002. Instead, the terms of the Facility Agreement are “ambiguous 

and both sides present plausible interpretations of the [Facility Agreement] language.” Id. at 999. 

Accordingly, the Court concludes that Anthem did not abuse its discretion in interpreting the 

Facility Agreement such that the emergency services rate applied to the Selected Claims. 

“[W]here the party moving for summary judgment has had a full and fair opportunity to prove its 

case, but has not succeeded in doing so, a court may enter summary judgment sua sponte for the 

nonmoving party.” Albino v. Baca, 747 F.3d 1162, 1176 (9th Cir. 2014). Here, Natividad has had 

a “full and fair opportunity” to prove that Anthem abused its discretion. Further, whether Anthem 

abused its discretion is a question of law that is suitable for the Court’s resolution based on review 

of the administrative record. See, e.g., Mason v. Fed. Express Corp., 165 F. Supp. 3d 832, 857 (D. 

Alaska 2016) (“In cases where the abuse of discretion standard applies, whether the administrator 

abused its discretion is a question of law, not fact, based on a review of the administrative record, 

as opposed to a trial.”).

Accordingly, the Court GRANTS Anthem’s motion for summary judgment with respect to 

the Selected Claims on the basis that Anthem did not abuse its discretion in interpreting the

Facility Agreement. The Court therefore does not reach Anthem’s alternative arguments that 

Anthem is not a proper defendant in the instant case. Because the Court concludes that Anthem 

did not abuse its discretion the Court must also DENY Natividad’s motion for summary judgment

with respect to the Selected Claims. See, e.g., Lisa O. v. Blue Cross of Idaho Health Serv. Inc., 

No. 1:12–cv–00285–EJL–REB, 2015 WL 3439847, at *11 (D. Idaho May 28, 2015) (“[T]his 

Court finds the Defendants did not abuse their discretion in denying the claim based on Exclusion 

P. For that reason, the Court will deny Plaintiffs’ Motion for Summary Judgment and grant the 

Defendants’ Motion for Summary Judgment.”).

B. Natividad’s Motion to Strike Is Moot.

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ORDER GRANTING ANTHEM’S MOTION FOR SUMMARY JUDGMENT AND DENYING NATIVIDAD’S 

MOTION FOR SUMMARY JUDGMENT

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On November 1, 2019, Natividad filed a motion to strike and exclude the “report, opinions, 

declaration, and any other testimony” of Anthem’s expert, Randall J. Moon. See ECF No. 113 at 

1. As Natividad notes, “Anthem has designated Randall J. Moon as a purported expert to opine 

that Anthem was neither a named fiduciary nor a ‘de facto’ fiduciary in connection with its actions 

in this case.” Id. This represents the sole subject of Randall J. Moon’s expert report. See ECF 

No. 93-1. However, the Court does not reach the issue of whether Anthem was a named or de 

facto fiduciary in the instant case, nor does the instant Order rely on the testimony of Randall J. 

Moon in any way. Accordingly, the Court DENIES as moot Natividad’s motion to strike the 

testimony of Randall J. Moon. See, e.g., In re Facebook Privacy Litig., No. 10-cv-02389-RMW, 

2016 WL 4585817, at *1 (N.D. Cal. Sept. 2, 2016) (“As the court does not reach the parties’

arguments with respect to damages, Facebook’s motion to strike the expert opinions of Forrest 

Vickery is denied as moot.”).

IV. CONCLUSION

For the foregoing reasons, the Court GRANTS Anthem’s motion for summary judgment. 

The Court DENIES Natividad’s motion for summary judgment.

IT IS SO ORDERED.

Dated: February 12, 2020

______________________________________

LUCY H. KOH

United States District Judge

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