Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-5_18-cv-07454/USCOURTS-cand-5_18-cv-07454-3/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.

---

1

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

SAN JOSE DIVISION

BENJAMIN WISE,

Plaintiff,

v.

MAXIMUS FEDERAL SERVICES, INC., 

et al.,

Defendants.

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S 

MOTION FOR PARTIAL SUMMARY 

JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR 

SUMMARY JUDGMENT; GRANTING 

IN PART DEFENDANT MAXIMUS’S 

MOTION FOR SUMMARY 

JUDGMENT

Re: Dkt. Nos. 157, 159, 162

Plaintiff Benjamin Wise brings suit against Defendants United HealthCare Services, Inc. 

and UnitedHealthCare Insurance Co. (collectively, “UHC”), as well as Defendant MAXIMUS 

Federal Services, Inc. (“MAXIMUS”), with regard to a denial of benefits to which Plaintiff claims 

he is entitled under his health insurance plan, which is covered by the Employee Retirement 

Income Security Act (“ERISA”). Before the Court are Plaintiff’s motion for partial summary 

judgment, Defendant UHC’s motion for summary judgment, and Defendant MAXIMUS’s motion 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 1 of 41
2

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

for summary judgment.

1

 Having considered the submissions of the parties, the relevant law, and 

the record in this case, the Court DENIES Plaintiff’s motion for partial summary judgment; 

GRANTS in part Defendant UHC’s motion for summary judgment; and GRANTS in part 

Defendant MAXIMUS’s motion for summary judgment.

I. BACKGROUND

A. Factual Background

The Court overviews the structure of Plaintiff’s insurance plan, the nature of independent

medical review under California law, and the facts surrounding Plaintiff’s allegations.

1. Plaintiff’s Insurance Plan

Plaintiff’s employer, Eric Miller Architects, participates in the Monterey County 

Hospitality Association Health & Welfare Plan (the “Plan”). Pursuant to the Plan’s Summary Plan 

Description, “[b]enefits under the Plan are provided by certain insurance providers contracting 

with the Trust, and are subject to the provisions of the Plan, the Trust Agreement, your employer’s 

Adoption Agreement, and the determination of the Plan Administrator or health insurance 

issuer(s).” UHC 108.2 The Plan provides medical benefits through Defendant UHC. UHC 111–

12. 

Defendant UHC, in turn, promulgates a Certificate of Coverage that “describe[s] [] 

Benefits, as well as [] rights and responsibilities, under the Policy.” UHC 174. The Certificate of 

Coverage dictates that Defendant UHC will “pay Benefits for Covered Health Services as 

described in Section 1: Covered Health Services and in the Schedule of Benefits, unless the service 

is excluded in Section 2: Exclusions and Limitations.” UHC 177. The Certificate of Coverage 

1 Plaintiff’s motion for partial summary judgment and Defendant MAXIMUS’s motion for 

summary judgment contain notices of motion that are separately paginated from the memoranda of 

points and authorities in support of the motions. See ECF No. 159 at i; ECF No. 162 at 1–2. Civil 

Local Rule 7-2(b) provides that the notice of motion and points and authorities should be 

contained in one document with a combined page limit. See Civ. Loc. R. 7-2(b).

2 Citations to the portion of the administrative record filed by Defendant UHC are notated with the 

word “UHC.” Citations to the portion of the administrative record filed by Defendant MAXIMUS 

are notated with the word “MAX.”

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 2 of 41
3

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

outlines various “Covered Health Services.” UHC 180. In order to qualify as a “Covered Health 

Service,” a treatment or device must be “Medically Necessary.” Id. “Medically Necessary” is 

defined by the Certificate of Coverage as follows:

[H]ealth care services provided for the purpose of preventing, evaluating, diagnosing 

or treating a health condition, Mental Illness, substance-related and addictive 

disorders, condition, disease or its symptoms, that are all of the following.

• In accordance with Generally Accepted Standards of Medical Practice.

• Clinically appropriate, in terms of type, frequency, extent, site and duration, and 

considered effective for your health condition, Mental Illness, substance-related and 

addictive disorders, disease or its symptoms.

• Not mainly for your convenience or that of your doctor or other health provider.

• Not more costly than an alternative drug, service(s) or supply that is at least as likely 

to produce equivalent therapeutic or diagnostic results as to the diagnosis or 

treatment of your health condition, disease or symptoms.

UHC 253. “Covered Health Services” includes certain types of “durable medical equipment.” 

UHC 185. Specifically, “Covered Health Services” includes:

Durable Medical Equipment that meets each of the following criteria:

• Ordered or provided by a Physician for outpatient use primarily in a home setting.

• Used for medical purposes.

• Not consumable or disposable except as needed for the effective use of covered 

Durable Medical Equipment.

• Not of use to a person in the absence of a disease or disability.

Id. The Certificate of Coverage further specifies that “[b]enefits under this section do not include 

any device, appliance, pump, machine, stimulator, or monitor that is fully implanted into the 

body.” Id.

A different section of the Certificate of Coverage outlines “Exclusions and Limitations.” 

UHC 203. The exclusions include “Experimental or Investigational and Unproven Services.” 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 3 of 41
4

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

UHC 206. The Certificate of Coverage specifically defines both “Experimental or Investigational 

Service(s),” UHC 250, as well as “Unproven Service(s),” UHC 258. As to the former, the 

Certificate of Coverage defines “Experimental or Investigational Service(s)” as:

medical, surgical, diagnostic, psychiatric, mental health, substance-related and 

addictive disorders or other health care services, technologies, supplies, treatments, 

procedures, drug therapies, medications or devices that, at the time a determination 

is made regarding coverage in a particular case, are any of the following:

• Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully 

marketed for the proposed use and not identified in the American Hospital Formulary 

Service or the United States Pharmacoepia Dispensing Information as appropriate 

for the proposed use.

• Subject to review and approval by any institutional review board for the proposed 

use. (Devices which are FDA approved under the Humanitarian Use Device 

exemption are not considered to be Experimental or Investigational.)

• The subject of an ongoing clinical trial that meets the definition of a Phase I, II or III 

clinical trial set forth in the FDA regulations, regardless of whether the trial is 

actually subject to FDA oversight.

UHC 250. As to the latter, the Certificate of Coverage defines “Unproven Service(s)” as:

Services, including medications, that are not effective for treatment of the medical 

condition and/or not to have [sic] a beneficial effect on health outcomes due to 

insufficient and inadequate clinical evidence from well-conducted randomized 

clinical trials or cohort studies in the prevailing published peer-reviewed medical 

literature.

• Well-conducted randomized clinical trials. (Two or more treatments are compared 

to each other, and the patient is not allowed to choose which treatment is received.)

• Well-conducted cohort studies from more than one institution. (Patients who receive 

study treatment are compared to a group of patients who receive standard therapy. 

The comparison group must be nearly identical to the study treatment group.)

UHC 258.3 

The Certificate of Coverage goes on to explain that Defendant UHC has “a process by 

3 The Court addresses a discrepancy concerning this language, infra Section III.C.2.

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 4 of 41
5

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

which we compile and review clinical evidence with respect to certain health services. From time 

to time, we issue medical and drug policies that describe the clinical evidence available with 

respect to specific health services. These medical and drug policies are subject to change without 

prior notice.” Id.

Specifically, Defendant UHC promulgates a document called the “Omnibus Codes.” UHC 

353. The Omnibus Codes are a “Medical Policy [that] provides assistance in interpreting 

[Defendant UHC’s] benefit plans.” Id. However, the Omnibus Codes dictate that “[w]hen 

deciding coverage, the member specific benefit plan document must be referenced.” Id. Indeed, 

the Omnibus Codes state that “[t]he terms of the member specific benefit plan document (e.g., 

Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description 

(SPD)) may differ greatly from the standard benefit plan upon which this Medical Policy is 

based.” Id. The Omnibus Codes also state that “[i]n the event of a conflict, the member specific 

benefit plan document supersedes this Medical Policy.” Id.

The Omnibus Codes discuss the “MyoPro myoelectric limb orthosis,” the medical device 

at the center of the instant case. UHC 449. The Omnibus Codes state that “[t]he use of the upper 

limb orthotic known as the MyoPro orthosis is unproven and not medically necessary due to 

insufficient clinical evidence and/or efficacy in published peer-reviewed medical literature.” Id. 

To justify this conclusion, the Omnibus Codes discuss three separate publications that concluded, 

inter alia, that “[a]dding MyoPro to supervised therapy provided little to no additional benefit”; 

that “myoelectric bracing may be more beneficial than [repetitive task practice] only in improving 

self-reported function and perceptions of overall recovery”; and that “therapist supervised taskspecific practice with an integrated robotic device could be as efficacious as manual practice in 

some subjects with moderate upper extremity impairment.” Id. Defendant UHC also promulgates 

a “Coverage Determination Guideline” that discusses coverage for “Durable Medical Equipment” 

such as orthotics and “Prosthetic Devices . . . [and] Myoelectric Limbs.” UHC 339–52.

2. Independent Medical Review Process

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 5 of 41
6

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

The Certificate of Coverage provides for an internal appeals process for adverse 

determinations made by Defendant UHC. UHC 227. The Certificate of Coverage also 

contemplates an “Independent External Review Program.” UHC 229. Specifically, the Certificate 

of Coverage explains that “[i]f we deny Benefits because it was determined that the treatment is 

not Medically Necessary or was an Experimental, Investigational or Unproven Service, you may 

request an Independent Medical Review (IMR) from the California Department of Insurance

(CDI) at no cost to you.” Id. In order for a beneficiary to take advantage of the independent 

medical review process, the beneficiary “must first file an appeal of the denial with [Defendant 

UHC].” Id. The Certificate of Coverage explains that “[i]f [Defendant UHC] uphold[s] our 

decision or delay[s] responding to your appeal/grievance, then you may file a Request for 

Assistance or an [Independent Medical Review] request with the California Department of 

Insurance.” Id.

The Certificate of Coverage dictates that an independent medical review may be requested 

for only certain types of denials. Id. Of relevance here, the Certificate of Coverage explains that 

independent medical review may be requested for “[h]ealth claims that have been denied, 

modified, or delayed by [Defendant UHC] because a Covered Health Service or treatment was not 

considered medically necessary.” Id. The Certificate of Coverage also dictates that independent 

medical review may be requested for “[h]ealth claims that have been denied as being 

Experimental, Investigational or Unproven Services.” Id.

The Certificate of Coverage indicates that in an independent medical review, “expert 

independent medical professional[s] review the medical decisions made by [Defendant UHC] and 

often decide in favor of the Covered Person getting the medical treatment requested.” Id. Further, 

the Certificate of Coverage states that “[t]he decision [that results from the independent medical 

review] is binding on [Defendant UHC].” UHC 230.

The California Department of Insurance contracts with third-party entities to perform the 

independent medical reviews contemplated by the Certificate of Coverage. MAX 1. Defendant 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 6 of 41
7

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

MAXIMUS is one such entity. Id. Independent medical reviewers like Defendant MAXIMUS 

are statutorily authorized to review certain insurer decisions on “whether [a] disputed health care 

service was medically necessary,” Cal. Ins. Code § 10169.3(b), as well as “decision[s] to deny, 

delay, or modify experimental or investigational therapies,” Cal. Ins. § 10145.3(b). When the 

California Department of Insurance receives a request for an independent medical review, the 

California Department of Insurance determines whether the underlying decision is eligible for 

independent medical review under one of these two categories. UHC 229. 

When an independent medical reviewer such as Defendant MAXIMUS performs a review 

of an insurer’s “decision to deny, delay, or modify experimental or investigational therapies,” Cal. 

Ins. § 10145.3(b), California law sets out requirements for how the review is conducted. Of 

relevance here, pursuant to California law, independent medical reviewers must provide “the 

reasons the requested therapy is or is not likely to be more beneficial for the insured than any 

available standard therapy, and the reasons that the expert recommends that the therapy should or 

should not be covered by the insurer, citing the insured’s specific medical condition, the relevant 

documents, and the relevant medical and scientific evidence, including, but not limited to, the 

medical and scientific evidence as defined in subdivision (d), to support the expert’s 

recommendation.” Cal. Ins. Code § 10145.3(c)(3). 

3. Plaintiff’s Request for Coverage of the MyoPro

In 2002, Plaintiff was involved in a vehicular accident that rendered Plaintiff’s left arm 

weakened and numb. UHC 41. On July 5, 2017, Plaintiff was examined by his doctor, Dr. Ken 

Hashimoto, who assessed Plaintiff and discussed a possible referral for a myoelectric orthotic 

manufactured by Myomo, Inc. (“Myomo”). UHC 48. Specifically, Myomo manufactures a 

myoelectric elbow-wrist-hand orthosis known as the MyoPro Motion G (“MyoPro”). UHC 43–

44. The MyoPro orthosis works by detecting a patient’s own neurological signals through sensors 

on the arm, in order to amplify a patient’s weak neural signal to help move the limb. Id.

Dr. Ken Hashimoto referred Plaintiff to the Valley Institute of Prosthetics and Orthotics 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 7 of 41
8

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

for further evaluation by certified prosthetists and orthotists. UHC 41, 48. The Valley Institute of 

Prosthetics and Orthotics determined that Plaintiff met the criteria to use a myoelectric elbowwrist-hand orthosis. UHC 41.

On September 19, 2017, Dr. Brandon Green, a physician consultant for the Valley Institute 

of Prosthetics and the Chief Medical Officer of Myomo, submitted a request for coverage of the 

MyoPro for use by Plaintiff to Defendant UHC. UHC 41. As part of the submission, Dr. Brandon 

Green prepared a history and physical exam review of Plaintiff and his condition. UHC 41–44. 

Dr. Brandon Green opined that a myoelectric orthosis is the “best available technology” to help 

provide functionality to Plaintiff’s left arm. Id. Dr. Brandon Green explained that Plaintiff had 

undertaken numerous other treatments that had not restored Plaintiff’s left arm function. Id. 

Moreover, Dr. Brandon Green asserted that “there is a wealth of well-designed, peer-reviewed, 

published studies over the course of six decades which prove the standardized clinical efficacy and 

superiority of robotic, myoelectric technology over traditional, less sophisticated treatment 

alternatives for neurological impairments such as [that of Plaintiff].” Id. Dr. Brandon Green cited 

nineteen publications in connection with the history and physical exam review. Id. 

In correspondence dated October 10, 2017, Defendant UHC denied Plaintiff’s request for 

coverage of the MyoPro orthotic. UHC 35. As rationale for the decision, Defendant UHC stated 

as follows: “Here is the specific clinical reason for our decision. We have received a request for a 

new artificial arm for you. You had an injury to the nerves of the arm. We reviewed the 

information received. We reviewed your benefit plan’s document. We reviewed your health 

plan’s medical policy for artificial limbs. This request does not meet your health plan’s coverage 

criteria. The code submitted is incorrect and a more specific code should be provided. Your 

health plan covers only the most cost effective equipment to meet your needs. This request may 

not be the most cost effective one. Thus this request is not covered under your health plan.” UHC 

36. Defendant UHC informed Plaintiff of Plaintiff’s right to an internal appeal, as well as 

Plaintiff’s opportunity to seek an independent medical review in the event that the internal appeal 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 8 of 41
9

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

was denied. UHC 36–38. Defendant UHC indicated that the denial was based in part on 

Defendant UHC’s written policy on “Durable Medical Equipment,” as well as Defendant UHC’s 

written policy on “Prosthetic Devices.” UHC 35.

4. Plaintiff’s Appeal with Defendant UHC

On November 22, 2017, Dr. Brandon Green filed an appeal of Defendant UHC’s denial of 

benefits to Defendant UHC’s Appeals Unit. UHC 31. Dr. Brandon Green argued that the 

“Prosthetic Devices” policy was inapplicable to Plaintiff’s request for coverage of the MyoPro. 

UHC 32. Dr. Brandon Green also argued that the MyoPro met each of the requirements outlined 

in Defendant UHC’s written policy on “Durable Medical Equipment.” Id. Finally, Dr. Brandon 

Green informed Defendant UHC that the coverage request had in fact been submitted with the 

correct code. Id.

On December 11, 2017, Defendant UHC denied Plaintiff’s appeal. UHC 74. Specifically, 

in a letter to Plaintiff, Defendant UHC stated as follows: “The request to cover a device 

(MYOPRO) for you was reviewed. We looked at the notes sent to us. We looked at your health 

plan benefits. The notes show that you have arm weakness (brachial plexopathy). The requested 

device has not been shown to help your condition. It cannot be covered. The denial is upheld.” 

UHC 78. Defendant UHC cited numerous provisions from the Certificate of Coverage, including 

the Certificate of Coverage’s definition of “Medically Necessary” as well as the Certificate of 

Coverage’s exclusion for “Experimental or Investigational and Unproven Services.” UHC 76. 

Defendant UHC also indicated that the decision was based in part on Defendant UHC’s Omnibus 

Codes, along with Defendant UHC’s written policies on “Prosthetic Devices” and “Durable 

Medical Equipment.” UHC 78. Defendant UHC also advised Plaintiff that Plaintiff had 

exhausted the internal appeal process, and that Plaintiff had the right to an independent medical 

review through the California Department of Insurance. UHC 79. 

5. Plaintiff’s Independent Medical Review with Defendant MAXIMUS

Shortly after the denial of benefits by Defendant UHC’s Appeals Unit, on December 11, 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 9 of 41
10

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

2017, Plaintiff filed a request for an independent medical review with the California Department 

of Insurance. MAX 18. On January 26, 2018, Dr. Brandon Green filed a letter in support of 

Plaintiff’s independent medical review application, along with supporting documentation. MAX 

550. In the letter, Dr. Brandon Green criticized the three publications that were cited by 

Defendant UHC’s Omnibus Codes to support Defendant UHC’s noncoverage of the MyoPro. 

MAX 552. Dr. Brandon Green also enclosed two previous determinations by Defendant 

MAXIMUS in January and September 2017 that the MyoPro was “likely to be more beneficial for 

treatment of [a particular patient’s] medical condition than any available standard therapy.” MAX 

610, 619. One of these patients suffered from paralysis in the left arm because of a vehicular 

accident, like Plaintiff. MAX 610.

Defendant MAXIMUS conducted the independent medical review, and the review was 

conducted by “three independent physician consultants who have no affiliation with” Defendant 

UHC. MAX 2. Each of the three reviewers employed by Defendant MAXIMUS received copies 

of Plaintiff’s medical records, the letters of Dr. Brandon Green, the Certificate of Coverage, and 

several of Defendant UHC’s medical policies. MAX 4–12. In Defendant MAXIMUS’s final 

report, Defendant MAXIMUS then certified that the reviewers “examined all of the medical 

records and documentation submitted” to reach their conclusions. MAX 2. Each of the reviewers 

also “performed a search of the relevant medical literature” and relied on additional publications 

generated by the search. MAX 4–12. Each reviewer concluded that “the requested equipment is 

not likely to be more beneficial for treatment of the [Plaintiff’s] medical condition than any 

available standard therapy.” MAX 2. Accordingly, Defendant MAXIMUS declared that 

Defendant UHC’s “denial has been upheld.” Id. Defendant MAXIMUS informed Plaintiff that 

Plaintiff “cannot appeal this decision. The Department of Insurance does not accept appeals of a 

MAXIMUS decision. The decision of MAXIMUS is final.” Id.

B. Procedural History

On December 11, 2018, Plaintiff filed suit against Defendants MVI Administrators 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 10 of 41
11

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

Insurance Solutions, Inc., Monterey County Hospitality Association Health and Welfare Trust, 

Monterey County Hospitality Association, UHC, and MAXIMUS. ECF No. 1. Plaintiff’s initial 

complaint alleged three causes of action against all defendants: (1) wrongful denial of benefits 

under ERISA §502(a)(1)(B), 28 U.S.C. §1132; (2) breach of fiduciary duty under ERISA § 

502(a)(3), 29 U.S.C. § 1132(a)(3); and (3) denial of full and fair review under ERISA § 503, 29 

U.S.C. § 1133. Id. ¶¶ 66–87. 

On March 15, 2019, Defendant Monterey County Hospitality Association Health and 

Welfare Trust filed a cross-claim against United HealthCare Services, Inc. and a third-party 

complaint against Third-Party Defendant Eric Miller Architects, Plaintiff’s employer. ECF No. 

37.

On April 26, 2019, Defendant UHC filed a motion to compel binding arbitration as to 

Defendant Monterey County Hospitality Association Health and Welfare Trust’s cross-claim. 

ECF No. 54. On April 26, 2019, Defendant MVI Administrators Insurance Solutions, Inc. also 

filed a motion to dismiss Plaintiff’s complaint as to Defendant MVI Administrators Insurance 

Solutions, Inc. ECF No. 55. 

On May 22, 2019, Defendant Monterey County Hospitality Association also filed a crossclaim against United HealthCare Services, Inc. and a third-party complaint against Third-Party 

Defendant Eric Miller Architects. ECF No. 80.

On June 26, 2019, Third-Party Defendant Eric Miller Architects filed a motion to dismiss 

Defendant Monterey County Hospitality Association’s third-party complaint. ECF No. 90.

On July 2, 2019, the Court granted MVI Administrators Insurance Solutions, Inc.’s motion 

to dismiss the complaint without prejudice. ECF No. 93. On July 18, 2019, Defendant Monterey 

County Hospitality Association and Third-Party Defendant Eric Miller Architects stipulated to 

dismiss Defendant Monterey County Hospitality Association’s third-party complaint with 

prejudice. ECF No. 97. The Court granted the stipulation and denied Third-Party Defendant Eric 

Miller Architects’ motion to dismiss as moot. Id.

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 11 of 41
12

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

On August 1, 2019, Plaintiff filed a first amended complaint (“FAC”). ECF No. 101 

(“FAC”). Plaintiff’s FAC alleges the same three causes of action that Plaintiff’s initial complaint 

alleged. Id. at ¶¶ 69–96. 

Later, on August 5, 2019, the Court granted Defendant United HealthCare Services, Inc.’s 

motion to compel binding arbitration as to Defendant Monterey County Hospitality Association 

Health and Welfare Trust’s cross-claim. ECF No. 102.

On August 26, 2019, the Court then granted a stipulation between Defendant Monterey 

County Hospitality Association Health and Welfare Trust and Third-Party Defendant Eric Miller 

Architects to dismiss Defendant Monterey County Hospitality Association Health and Welfare 

Trust’s third-party complaint with prejudice. ECF No. 114. With that stipulation, Third-Party 

Defendant Eric Miller Architects was no longer a party to the instant case.

On August 30, 2019, Defendant MVI Administrators Insurance Solutions, Inc. filed a 

motion to dismiss the FAC as to Defendant MVI Administrators Insurance Solutions, Inc. ECF 

No. 128.

On November 8, 2019, the Court granted a stipulation between Defendant United 

HealthCare Services, Inc. and Defendant Monterey County Hospitality Association to dismiss 

Defendant Monterey County Hospitality Association’s cross-claim with prejudice. ECF No. 142.

On November 15, 2019, the Court then granted a stipulation between Plaintiff and 

Defendants Monterey County Hospitality Association and Monterey County Hospitality 

Association Health and Welfare Trust that dismissed Plaintiff’s claims against those two entities 

with prejudice. ECF No. 145. With that stipulation, Defendants Monterey County Hospitality 

Association and Monterey County Hospitality Association Health and Welfare Trust were no 

longer parties to the instant case.

On January 21, 2020, the Court granted Defendant MVI Administrators Insurance 

Solutions, Inc.’s motion to dismiss the FAC as to Defendant MVI Administrators Insurance 

Solutions, Inc. with prejudice. ECF No. 154. With that order, Defendant MVI Administrators 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 12 of 41
13

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

Insurance Solutions, Inc. was no longer a party to the instant case.

Accordingly, by the January 24, 2020 deadline for dispositive motions, only three parties 

remained in the instant case: Plaintiff, Defendant UHC, and Defendant MAXIMUS. On January 

24, 2020, Defendant UHC and Defendant MAXIMUS moved for summary judgment, and Plaintiff 

moved for partial summary judgment. ECF Nos. 157 (“UHC Mot.”), 159 (“MAXIMUS Mot.”), 

162 (“Plaintiff Mot.”).

On February 14, 2020, Defendant UHC opposed Plaintiff’s motion for partial summary 

judgment, and vice versa. ECF Nos. 170 (“UHC Opp’n”), 172 (“Plaintiff First Opp’n”). 

Defendant UHC also objected to exhibits that Plaintiff filed in support of Plaintiff’s motion for 

partial summary judgment. ECF No. 171.4

On February 18, 2020, Defendant MAXIMUS opposed Plaintiff’s motion for partial

summary judgment, and vice versa. ECF Nos. 173 (“MAXIMUS Opp’n”), 174 (“Plaintiff Second 

Opp’n”).

II. LEGAL STANDARD

A. Standard of Review in ERISA Cases

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). 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 

4 On February 27, 2020, Defendant UHC also filed a reply in support of Defendant UHC’s motion 

for summary judgment. ECF No. 176. However, the operative briefing schedule did not permit 

replies. ECF No. 79. Accordingly, on February 28, 2020, Defendant UHC withdrew the reply. 

ECF No. 177. The Court does not consider the unauthorized filing in resolving the instant 

motions.

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 13 of 41
14

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

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 (2008).

B. Summary Judgment Standard of Review

Summary judgment is appropriate if, viewing the evidence and drawing all reasonable 

inferences in the light most favorable to the nonmoving party, there are no genuine disputes of 

material fact, and the movant is entitled to judgment as a matter of law. Fed. R. Civ. P. 56(a); 

Celotex Corp. v. Catrett, 477 U.S. 317, 321 (1986). A fact is “material” if it “might affect the 

outcome of the suit under the governing law,” and a dispute as to a material fact is “genuine” if 

there is sufficient evidence for a reasonable trier of fact to decide in favor of the nonmoving party. 

Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986).

III. DISCUSSION

The parties’ motions for summary judgment raise numerous issues that the Court must 

resolve. First, the Court addresses the applicable standard of review and the application of Rule 

56 in this context. Second, the Court addresses numerous arguments by Defendant MAXIMUS 

makes to the effect that Defendant MAXIMUS is not a proper defendant in the instant case. 

Third, the Court addresses Plaintiff’s claim for improper denial of ERISA benefits pursuant to 

ERISA § 502(a)(1)(B). Fourth, the Court addresses Plaintiff’s claim for breach of fiduciary duty 

pursuant to ERISA § 502(a)(3). Fifth, and finally, the Court addresses Plaintiff’s claim for denial 

of full and fair review under ERISA § 503.

A. Applicable Standard of Review

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) (“[ERISA § 502(a)(1)(B)] is relatively 

straightforward. If a participant or beneficiary believes that benefits promised to him under the 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 14 of 41
15

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

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) 

(explaining that the default standard is de novo). 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 (2008) (explaining that abuse of discretion applies if the terms of the plan provide as 

much).

Here, the parties each agree that de novo review is the appropriate standard for the Court to 

employ. UHC Mot. at 7 (“There is no dispute between the parties that this Court will review this 

case de novo.”); MAXIMUS Mot. at 9 (“Under Plaintiff’s first claim (section 502(a)(1)(B) of 

ERISA), the standard of review would be de novo.”); Plaintiff Mot. at 8 (“The De Novo Standard 

of Review Applies.”). Accordingly, the Court evaluates Plaintiff’s denial of benefits claim in the 

instant case de novo. See Rorabaugh v. Cont’l Cas. Co., 321 F. App’x 708, 709 (9th Cir. 2009) 

(holding that the court may accept parties stipulation to de novo review). 

A court that employs de novo review in an ERISA case “simply proceeds to evaluate 

whether the plan administrator correctly or incorrectly denied benefits.” Abatie v. Alta Health & 

Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 2006). Generally, the court’s review is limited to the 

evidence contained in the administrative record. Opeta v. Nw. Airlines Pension Plan for Contract 

Employees, 484 F.3d 1211, 1217 (9th Cir. 2007) (explaining that in de novo ERISA case, 

“extrinsic evidence could be considered only under certain limited circumstances”). The Ninth 

Circuit has explained that the Court may, in its discretion, “allow evidence that was not before the 

plan administrator.” Mongeluzo v. Baxter Travenol Long Term Disability Ben. Plan, 46 F.3d 938, 

943–44 (9th Cir. 1995) (internal quotation marks omitted). “The district court should exercise its 

discretion, however, only when circumstances clearly establish that additional evidence is 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 15 of 41
16

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

necessary to conduct an adequate de novo review of the benefit decision.” Id. at 944 (internal 

quotation marks omitted). “In most cases,” the Ninth Circuit has explained, “where additional 

evidence is not necessary for adequate review of the benefits decision, the district court should 

only look at the evidence that was before the plan administrator.” Id. (internal quotation marks 

omitted). Here, Plaintiff and Defendant MAXIMUS both seek to introduce evidence that is not in 

the administrative record and that was therefore not before the plan administrator. E.g., ECF Nos. 

159-2, 163. Neither party provides any argument as to why additional evidence is “necessary for 

adequate review of the benefits decision.” Mongeluzo, 46 F.3d at 944 (internal quotation marks 

omitted). Accordingly, for the purpose of assessing the instant motions, the Court’s review will be 

confined to the administrative record.

The parties bring motions for summary judgment under Rule 56. Plaintiff Mot. at 1 (citing 

Federal Rule of Civil Procedure 56); UHC Mot. at 12 (requesting that the Court enter “summary 

judgment” for Defendant UHC); MAXIMUS Mot. at 2 (citing Federal Rule of Civil Procedure 

56). To the extent that Defendant UHC requests that the Court “conduct a trial on the 

administrative record,” Defendant UHC’s request is premature. UHC Mot. at 7. Instead, as the 

Ninth Circuit has explained, “[s]ummary judgment in an ERISA case is only proper where there 

are no genuine disputes of material fact, and the movant is entitled to judgment as a matter of 

law.” Gordon v. Met. Life Ins. Co., 747 F. App’x 594, 595 (9th Cir. 2019); see also Spencer v. 

Caterpillar, Inc. Non-Contributory Pension Plan, No. C02-2101 SI, 2003 WL 21148467, at *2 

(N.D. Cal. May 13, 2003) (“If the standard of review is de novo, then the district court may decide 

the case by summary judgment only if there are no genuine issues of material fact in dispute.”). 

Hence, ordinary Rule 56 principles guide the Court’s analysis. The Court now turns to the 

competing motions for summary judgment below, beginning with the arguments asserted by 

Defendant MAXIMUS. 

B. Defendant MAXIMUS Is a Proper Defendant

In Defendant MAXIMUS’s motion for summary judgment, Defendant MAXIMUS makes 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 16 of 41
17

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

numerous arguments that Defendant MAXIMUS is not a proper defendant as to Plaintiff’s claims. 

First, Defendant MAXIMUS contends that Defendant MAXIMUS is not an ERISA fiduciary. 

Second, Defendant MAXIMUS argues that Defendant MAXIMUS may not be sued under ERISA

§ 502(a)(1)(B). Third, and finally, Defendant MAXIMUS contends that Defendant MAXIMUS is 

statutorily immune from all of Plaintiff’s claims. The Court addresses, and ultimately rejects, each 

of these arguments in turn.

1. Defendant MAXIMUS Is a Functional Fiduciary

Defendant MAXIMUS contends that Defendant MAXIMUS is not an ERISA fiduciary. 

MAXIMUS Mot. at 6–8. According to Defendant MAXIMUS, Defendant MAXIMUS does not 

“exercise[] discretionary authority on behalf of the plan, its assets, or its administration,” and 

hence does not fit the statutory definition. Id. at 6. Plaintiff responds that “[b]y conducting 

[independent medical review]s and exercising discretion to decide whether to approve or deny 

benefits to a participant in an ERISA-governed welfare benefit plan, MAXIMUS acts as a 

‘functional’ fiduciary subjecting it to liability for its actions.” Plaintiff Second Opp’n at 7. The 

Court agrees with Plaintiff.

ERISA provides a definition of a “functional” fiduciary:

[A] person is a fiduciary with respect to a plan to the extent (i) he exercises any 

discretionary authority or discretionary control respecting management of such plan 

or exercises any authority or control respecting management or disposition of its 

assets, (ii) he renders investment advice for a fee or other compensation, direct or 

indirect, with respect to any moneys or other property of such plan, or has any 

authority or responsibility to do so, or (iii) he has any discretionary authority or 

discretionary responsibility in the administration of such plan.

29 U.S.C. § 1002(21)(A). In other words, to be a “functional” fiduciary, “the person or entity 

must have control respecting the management of the plan or its assets, give investment advice for a 

fee, or have discretionary responsibility in the administration of the plan.” Arizona State 

Carpenters Pension Trust Fund v. Citibank (Arizona), 125 F.3d 715, 722 (9th Cir. 1997). Indeed, 

ERISA defines “fiduciary” “not in terms of formal trusteeship, but in functional terms of control 

and authority over the plan.” Mertens v. Hewitt Assoc., 508 U.S. 248, 262 (1993) (emphasis in 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 17 of 41
18

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

original). 

“The [United States] Supreme Court has stressed that the central inquiry [into whether a 

party was an ERISA fiduciary] is whether the party was acting as an ERISA fiduciary ‘when 

taking the action subject to complaint.’” Santomenno v. Transamerica Life Ins. Co., 883 F.3d 833, 

838 (9th Cir. 2018) (quoting Pegram v. Herdrich, 530 U.S. 211, 226 (2000)). Specifically, 

because “a person is a fiduciary under this provision only ‘to the extent’ the person engages in the 

listed conduct, a person may be a fiduciary with respect to some actions but not others.” Depot, 

Inc., 915 F.3d at 654.

Here, Plaintiff argues that Defendant MAXIMUS served as a functional fiduciary in the 

instant case because Defendant MAXIMUS exercised “discretion to decide whether to approve or 

deny benefits to a participant in an ERISA-governed welfare benefit plan.” Plaintiff Second 

Opp’n at 7. The Northern District of California’s recent decision in Josef K. v. Cal. Physicians’ 

Serv., No. 18-CV-06385-YGR, 2019 WL 2342245 (N.D. Cal. June 3, 2019), is instructive. In 

Josef K., a plaintiff, E.K., brought a claim for breach of fiduciary duty under ERISA against 

Defendant MAXIMUS. Id. at *2. E.K. challenged Defendant MAXIMUS’s independent medical 

review of a claim denial, and E.K. alleged that Defendant MAXIMUS failed “to address facts and 

materials provided by E.K.’s parents and treatment providers, and [engaged in]

mischaracterization of E.K.’s condition and medical history in its final written report.” Id. 

Defendant MAXIMUS asserted in Josef K., as Defendant MAXIMUS does in the instant case, that 

Defendant MAXIMUS was not an ERISA fiduciary. Id. at *6.

The Josef K. court rejected Defendant MAXIMUS’s arguments. First, the Josef K. court 

found that Defendant MAXIMUS “exercised significant discretion” when Defendant MAXIMUS 

issued the relevant determination. Id. at *7. Second, the Josef K. court found that Defendant 

MAXIMUS’s determination was binding on the insurer, which “bestowed Maximus with final 

authority over whether E.K.’s claim would be paid or not.” Id. Third, and finally, the Josef K. 

court emphasized the fact that “the Plan expressly provides for an [independent medical review].” 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 18 of 41
19

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

Id. at *8.

All of the foregoing facts are present in the instant case. First, Defendant MAXIMUS 

determined whether the MyoPro was “experimental or investigative.” MAX 1. Under California 

law, this determination required Defendant MAXIMUS to provide “the reasons the requested 

therapy is or is not likely to be more beneficial for the insured than any available standard therapy, 

and the reasons that [Defendant MAXIMUS] recommends that the therapy should or should not be 

covered by the insurer, citing the insured’s specific medical condition, the relevant documents, and 

the relevant medical and scientific evidence, including, but not limited to, the medical and 

scientific evidence as defined in subdivision (d), to support [Defendant MAXIMUS’s] 

recommendation.” Cal. Ins. Code § 10145.3(c)(3). 

The record demonstrates that Defendant MAXIMUS “exercised significant discretion” to 

perform the foregoing inquiry. For instance, Defendant MAXIMUS exercised significant

discretion to determine the “relevant medical and scientific evidence,” which is “not limited” by 

the statute. Cal. Ins. Code § 10145.3(c)(3). Indeed, the reviewers employed by Defendant 

MAXIMUS “performed a search of the relevant literature” and each consulted numerous studies 

and medical authorities that the reviewers personally deemed to be relevant. MAX 5–12. Two of 

the reviewers relied on entirely different sources from each other. MAX 8, 11. Further, 

Defendant MAXIMUS’s ultimate determination of whether the MyoPro was “experimental or 

investigative” required Defendant MAXIMUS to determine whether the MyoPro “is or is not 

likely to be more beneficial for the insured than any available standard therapy” for Plaintiff. Cal. 

Ins. Code § 10145.3(c)(3). This standard is undefined and abstract. Defendant MAXIMUS 

possessed discretion to assess the likelihood that the MyoPro would provide medical benefits to 

Plaintiff and how to compare those benefits to an unspecified course of “standard therapy.” MAX 

6–12 (performing analysis). The Certificate of Coverage also does not impose any limits on 

Defendant MAXIMUS’s discretion. Indeed, the Certificate of Coverage only dictates that 

Defendant MAXIMUS would “review the medical decisions made by” Defendant UHC, so long 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 19 of 41
20

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

as Defendant UHC’s decision fell within the relevant defined categories. UHC 229.

Further, Defendant MAXIMUS possessed final authority over whether Plaintiff received 

the benefit in the instant case. The Certificate of Coverage dictates that “[t]he decision [of 

Defendant MAXIMUS] is binding” on Defendant UHC. UHC 230. The Certificate of Coverage 

also clearly indicates that the outcome of Defendant MAXIMUS’s determination would result in 

either payment for or denial of Plaintiff’s claim for the MyoPro. Id. Likewise, the California 

Department of Insurance’s description of Defendant MAXIMUS’s role in the independent medical 

review informed Plaintiff that Defendant MAXIMUS would assess whether the MyoPro is 

“experimental and excluded by a policy provision,” and the “decision will be binding on the 

insurance company.” MAX 135. 

Finally, as in Josef K., the Certificate of Coverage in the instant case specifically affords 

Plaintiff the right to independent medical review. UHC 230. As Defendant MAXIMUS concedes, 

the Certificate of Coverage is clearly a Plan document. MAXIMUS Mot. at 4 (“The pertinent Plan 

documents include . . . the Evidence of Coverage from UHC.”). Hence, Defendant MAXIMUS 

played an important role contemplated by the Plan itself when Defendant MAXIMUS provided 

Plaintiff with “expert independent medical professional review.” UHC 229. These facts 

demonstrate that Defendant MAXIMUS “ha[d] control respecting the management of the plan or 

its assets,” and as such, served as a functional fiduciary when Defendant MAXIMUS performed 

the independent medical review. 29 U.S.C. § 1002(21)(A); see, e.g., Hecht v. Summerlin Life & 

Health Ins. Co., 536 F. Supp. 2d 1236, 1243 (D. Nev. 2008) (“A person with the authority to grant 

or deny claims, or to review the denial of claims, for benefits under the relevant ERISA plan is a 

fiduciary.”).

Defendant MAXIMUS’s arguments to the contrary are unpersuasive. First, Defendant 

MAXIMUS attempts to distinguish Josef K. because Josef K. involved a motion to dismiss, not 

summary judgment. MAXIMUS Opp’n at 4. The difference is not significant here because, as 

outlined in the foregoing, the dispositive factors the Josef K. court discussed are all established by 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 20 of 41
21

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

the record in the instant case.

Second, Defendant MAXIMUS argues that Defendant MAXIMUS “does not make 

coverage decisions.” MAXIMUS Opp’n at 6. Instead, Defendant MAXIMUS “simply addresses 

the narrow questions presented regarding a given proposed treatment or service.” Id. The Josef K. 

court considered and rejected precisely the same argument. Josef K., 2019 WL 2342245, at *6 

(rejecting argument that Defendant MAXIMUS “was only responsible for providing an external 

review of a ‘discrete issue,’ namely, whether E.K.’s treatments were medically necessary based on 

generally accepted standards of care”). Defendant MAXIMUS appears to rely on the California 

statutory definition of “coverage decision.” See Cal. Ins. Code § 10169(b) (“A decision regarding 

a disputed health care service relates to the practice of medicine and is not a coverage decision.”). 

The label supplied by California law is immaterial because as noted above, ERISA defines 

“fiduciary” “not in terms of formal trusteeship, but in functional terms of control and authority 

over the plan.” Mertens, 508 U.S. at 262 (emphasis in original). As discussed in the foregoing, 

Defendant MAXIMUS exercised “control and authority” over disposition of the Plan assets, 

subject to Defendant MAXIMUS’s broad discretion.

Third, Defendant MAXIMUS argues that Defendant MAXIMUS is not a fiduciary because 

Defendant MAXIMUS was not “required to rely on [the Certificate of Coverage] or any other Plan 

documents” when Defendant MAXIMUS conducted the independent medical review. 

MAXIMUS Mot. at 7. As an initial matter, Defendant MAXIMUS’s contention is belied by the 

record. Indeed, the record in the instant case indicates that Defendant MAXIMUS did rely in part

on the Certificate of Coverage. Each of the three reviewers employed by Defendant MAXIMUS 

received a copy of the Certificate of Coverage. MAX 4–12. In Defendant MAXIMUS’s final 

report, Defendant MAXIMUS then certified that the reviewers “examined all of the medical 

records and documentation submitted” to reach their conclusions. MAX 2 (emphasis added). 

To the extent Defendant MAXIMUS argues that because Defendant MAXIMUS was not 

required to rely on the Certificate of Coverage, Defendant MAXIMUS cannot be a functional 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 21 of 41
22

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

fiduciary, Defendant MAXIMUS cites no authority to support that proposition. On the contrary, 

the fact that Defendant MAXIMUS could evidently choose on which documents to rely when it 

performed the role of independent medical reviewer only underscores how much discretion 

Defendant MAXIMUS wielded. See, e.g., Arizona State Carpenters Pension Trust Fund, 125 

F.3d at 721–22 (“A person or entity who performs only ministerial services or administrative 

functions within a framework of policies, rules, and procedures established by others is not an 

ERISA fiduciary.”).

Fourth, and finally, Defendant MAXIMUS contends that Defendant MAXIMUS is not a 

functional fiduciary because “the health plan was required to comply with California’s external 

review process, . . . and therefore had no independent relationship with MAXIMUS.” MAXIMUS 

Mot. at 8. Whether Defendant MAXIMUS and Defendant UHC had an “independent 

relationship” is irrelevant. As explained, “the central inquiry [into whether a party was an ERISA 

fiduciary] is whether the party was acting as an ERISA fiduciary ‘when taking the action subject 

to complaint.’” Santomenno, 883 F.3d 833, 838 (9th Cir. 2018) (quoting Pegram, 530 U.S. at 

226). In the instant case, Defendant MAXIMUS provided the independent medical review of 

Plaintiff’s claim, and Defendant MAXIMUS “exercised significant discretion” as to whether 

Plaintiff’s claim for the MyoPro would be paid. This is sufficient to render Defendant 

MAXIMUS a functional fiduciary in the instant case. The Court now turns to Defendant 

MAXIMUS’s argument that Defendant MAXIMUS is not a proper defendant under ERISA § 

502(a)(1)(B).

2. Defendant MAXIMUS Is a Proper Defendant as to Plaintiff’s ERISA § 

502(a)(1)(B) Claim

Defendant MAXIMUS asserts that Plaintiff may not assert a claim under ERISA § 

502(a)(1)(B) against Defendant Maximus. MAXIMUS Mot. at 5. Specifically, Defendant 

MAXIMUS contends that Defendant MAXIMUS “has no authority to interpret Plan documents in 

order to decide whether the terms of the Plan provide coverage of the MyoPro orthosis, and has no 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 22 of 41
23

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

authority to pay for coverage of the MyoPro orthosis.” Id. Plaintiff disagrees, and asserts that 

“[b]ecause MAXIMUS made a final and binding benefits determination that [Plaintiff’s] request 

for coverage of the MyoPro should be denied, it is a proper party subject to liability for its 

improper denial of benefits.” Plaintiff Second Opp’n at 4. The Court agrees with Plaintiff.

In Spinedex Physical Therapy USA Inc. v. United Healthcare of Arizona, 770 F.3d 1282 

(9th Cir. 2014), the Ninth Circuit provided guidance as to which parties constitute proper 

defendants for actions for improper denial of benefits under ERISA § 502(a)(1)(B). In Spinedex,

the Ninth Circuit explained that “proper defendants under § 1132(a)(1)(B) for improper denial of 

benefits at least include ERISA plans, formally designated plan administrators, insurers or other 

entities responsible for payment of benefits, and de facto plan administrators that improperly deny 

or cause improper denial of benefits.” Id. at 1297. The Ninth Circuit also explained that “[s]uits 

under § 1132(a)(1)(B) to recover benefits may be brought against the plan as an entity and against 

the fiduciary of the plan.” Id. (internal quotation marks omitted, emphasis in original). The 

ultimate question is whether an entity is a “logical defendant” for an action under ERISA § 

502(a)(1)(B). Id.

The Court concluded, supra, that Defendant MAXIMUS served as a functional fiduciary 

when Defendant MAXIMUS performed the independent medical review for Plaintiff. The record 

in the instant case also demonstrates that Defendant MAXIMUS “cause[d] improper denial of 

benefits” to Plaintiff, to the extent that the denial of MyoPro was in fact improper. See, e.g., Smith 

v. Univ. of S. Cal., No. LA CV18-06111 JAK (AFMx), 2019 WL 988681, at *4 (C.D. Cal. Jan. 22, 

2019) (“Based upon the filings and arguments presented, there is a basis to conclude that there are 

sufficient allegations that [Defendant’s] decision-making caused the alleged improper denial of 

benefits to Plaintiff.”). Indeed, as discussed in the foregoing, Defendant MAXIMUS’s decision in 

the independent medical review was binding on Defendant UHC. UHC 229–30. If Defendant 

MAXIMUS had made a different decision, Plaintiff would have received the MyoPro as a benefit 

of the Plan. Id. Under Spinedex, this is sufficient.

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 23 of 41
24

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

Defendant MAXIMUS’s arguments to the contrary are unpersuasive. First, Defendant 

MAXIMUS claims that “[b]y law, MAXIMUS is limited in its review here to an evaluation of 

whether a service/treatment is investigational in light of Plaintiff’s medical records and relevant 

standards in the scientific community.” MAXIMUS Mot. at 5. Defendant MAXIMUS’s 

contention is irrelevant. The Ninth Circuit has indicated that functional fiduciaries like Defendant 

MAXIMUS are proper defendants for claims under ERISA § 502(a)(1)(B) if they “cause improper 

denial of benefits” under ERISA. Spinedex, 770 F.3d at 1297–98. On the record in this case, 

Defendant MAXIMUS meets that definition.

Similarly, Defendant MAXIMUS argues that Defendant “MAXIMUS does not have ‘final 

authority’ with respect to a Plan,” because Defendant MAXIMUS lacked authority to “authorize 

or disallow benefit payments in cases where a dispute exists as to the interpretation of plan 

provisions.” MAXIMUS Mot. at 5. However, once again, the record demonstrates that Defendant 

MAXIMUS’s decision was “binding on the insurance company [i.e., Defendant UCH].” MAX

493. Accordingly, Defendant MAXIMUS represents a “logical defendant” as to Plaintiff’s claim 

for wrongful denial of benefits under ERISA § 502(a)(1)(B). The Court now turns to Defendant 

MAXIMUS’s argument that Defendant MAXIMUS is entitled to statutory immunity.

3. Defendant MAXIMUS Is Not Entitled to Statutory Immunity

Finally, Defendant MAXIMUS argues that Defendant MAXIMUS “is [] immune from 

each and all of Plaintiff’s claims.” MAXIMUS Mot. at 9. Specifically, Maximus contends that 

two provisions of California law, Cal. Civ. Code § 43.98 and Cal. Insurance Code § 10169.2(b), 

render Defendant MAXIMUS statutorily immune from Plaintiff’s claims. Id. The Court 

disagrees.

California Insurance Code § 10169.2(b) dictates that “[t]he independent medical review 

organizations and the medical professionals retained to conduct reviews shall be deemed to be 

medical consultants for purposes of Section 43.98 of the Civil Code.” Cal. Insurance Code § 

10169.2(b). As an independent medical review organization, Defendant MAXIMUS is therefore a 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 24 of 41
25

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

“medical consultant[] for purposes of Section 43.98 of the Civil Code.” Id.

California Civil Code § 43.98 has no applicability in the instant case. California Civil 

Code § 43.98 dictates that “[t]here shall be no monetary liability on the part of, and no cause of 

action shall arise against, any consultant on account of any communication by that consultant to 

the Director of the Department of Managed Health Care or any other officer, employee, agent, 

contractor, or consultant of the Department of Managed Health Care, when that communication is 

for the purpose of determining whether health care services have been or are being arranged or 

provided in accordance with the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 

(commencing with Section 1340) of Division 2 of the Health and Safety Code).” Cal. Civ. Code § 

43.98. In order for immunity to apply, the consultant must also make a number of further 

showings, such as absence of malice, reasonable effort to obtain facts, and more. Id.

In the instant case, the record is devoid of any communication between Defendant 

MAXIMUS and “the Director of the Department of Managed Health Care or any other officer, 

employee, agent, contractor, or consultant of the Department of Managed Health Care.” Id. 

Instead, the record shows that Defendant MAXIMUS was enlisted to perform the independent 

medical review by the California Department of Insurance, a separate California state agency. 

See, e.g., MAX 14 (letter from California Department of Insurance that requested that Defendant 

MAXIMUS conduct the independent medical review of Plaintiff’s dispute); MAX 490 (email 

from California Department of Insurance that requested that Defendant MAXIMUS conduct the 

independent medical review of Plaintiff’s dispute). Accordingly, Defendant MAXIMUS is not 

entitled to statutory immunity under California Civil Code § 43.98.

In sum, and in light of the foregoing, the Court concludes that Defendant MAXIMUS’s 

arguments for summary judgment on the basis that Defendant MAXIMUS is not a proper 

defendant in the instant case fail. The Court DENIES Defendant MAXIMUS’s motion for 

summary judgment to the extent that Defendant MAXIMUS asserts that Defendant MAXIMUS is 

not a proper defendant under ERISA § 502(a)(1)(B), that Defendant MAXIMUS is not an ERISA 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 25 of 41
26

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

fiduciary, and that Defendant MAXIMUS is statutorily immune from Plaintiff’s claims. 

The Court now proceeds to consider the parties’ specific arguments for summary judgment 

as to each of Plaintiff’s claims, starting with Plaintiff’s claim for wrongful denial of benefits under 

ERISA § 502(a)(1)(B).

C. Improper Denial of Benefits under ERISA § 502(a)(1)(B)

All three parties move for summary judgment in connection with Plaintiff’s claim for 

improper denial of benefits under ERISA § 502(a)(1)(B). Plaintiff contends that Plaintiff’s 

request for the MyoPro falls within the Certificate of Coverage’s definitions of “Covered Health 

Service” and “Durable Medical Equipment.” Plaintiff Mot. at 12–13; UHC 180, 185. Neither 

Defendant UHC nor Defendant MAXIMUS argues otherwise. Accordingly, the Court assumes 

for the sake of the instant motions that the MyoPro falls within these coverage definitions. 

Moreover, Plaintiff also contends that Plaintiff’s request for the MyoPro does not fall within the 

Certificate of Coverage’s exclusion for “Experimental or Investigational Service(s).” Plaintiff 

Mot. at 14. Once again, neither Defendant UHC nor Defendant MAXIMUS argues otherwise. 

Accordingly, the Court assumes for the instant motions that Plaintiff’s request for the MyoPro 

does not fall within the Certificate of Coverage’s exclusion for “Experimental or Investigational 

Service(s).” 

Instead, the parties’ dispute centers on the applicability of the Certificate of Coverage’s 

“Unproven Service(s)” exclusion. Specifically, the Certificate of Coverage defines “Unproven 

Service(s)” as:

Services, including medications, that are not effective for treatment of the medical 

condition and/or not to have [sic] a beneficial effect on health outcomes due to 

insufficient and inadequate clinical evidence from well-conducted randomized 

clinical trials or cohort studies in the prevailing published peer-reviewed medical 

literature.

• Well-conducted randomized clinical trials. (Two or more treatments are compared 

to each other, and the patient is not allowed to choose which treatment is received.)

• Well-conducted cohort studies from more than one institution. (Patients who receive 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 26 of 41
27

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

study treatment are compared to a group of patients who receive standard therapy. 

The comparison group must be nearly identical to the study treatment group.)

UHC 258. In an ERISA case that involves de novo review, the general rule is that the plaintiff 

bears the burden of demonstrating that a benefit is covered. See Muniz v. Amec Const. Mgmt., 

Inc., 623 F.3d 1290, 1294 (9th Cir. 2010) (“[W]hen the court reviews a plan administrator’s 

decision under the de novo standard of review, the burden of proof is placed on the claimant.”). 

Defendant UHC maintains that the general rule applies here. UHC Mot. at 7. Defendant UHC is 

incorrect.

Because the question before the Court is the applicability of an exclusion of coverage, the 

burden of proof in fact rests with Defendant UHC and Defendant MAXIMUS to show that the 

“Unproven Service(s)” provision applies. See Intel Corp. v. Hartford Acc. & Indem. Co., 952 F.2d 

1551, 1557 (9th Cir. 1991) (“In insurance litigation, while the burden is on the insurer to prove a 

claim covered falls within an exclusion, the burden is on the insured initially to prove that an event 

is a claim within the scope of the basic coverage.” (internal quotation omitted)); see also Dubaich

v. Connecticut Gen. Life Ins. Co., No. CV 11–10570 DMG (AJWx), 2013 WL 3946108, at *9 

(C.D. Cal. July 31, 2013) (“[Defendant] bears the burden of demonstrating that an exclusion 

applies.”). The burden of proof is preponderance of evidence. See, e.g., Filarsky v. Life Ins. Co. 

of N.A., 391 F.Supp.3d 928, 938 (N.D. Cal. 2019) (applying preponderance of evidence on ERISA 

case in de novo review). Moreover, “[u]nder general principles of insurance law, exclusions are 

construed narrowly.” Dowdy v. Met. Life Ins. Co., 890 F.3d 802, 810 (9th Cir. 2018).

Accordingly, the question before the Court is whether the record contains a genuine issue 

of material fact that would permit Defendant UHC and Defendant MAXIMUS to meet their 

burdens to demonstrate the applicability of the “Unproven Service(s)” exclusion. First, the Court 

considers the argument that the Omnibus Codes independently resolve the question. Second, the 

Court considers the argument that the medical evidence in the administrative record would permit 

Defendant UHC and Defendant MAXIMUS to demonstrate the applicability of the “Unproven 

Service(s)” exclusion.

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 27 of 41
28

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

1. The Omnibus Codes Do Not Resolve the Question of the Applicability of the 

“Unproven Service(s)” Exclusion

As an initial matter, Defendant UHC argues that the Omnibus Codes alone resolve the 

issue of whether the MyoPro is covered by the Plan. UHC Mot. at 9. The Court disagrees. The 

Omnibus Codes do not resolve the coverage issue.

According to Defendant UHC, the Omnibus Codes constitute “terms of the Plan” that are 

binding on Defendant UHC. Id. (“[T]he Omnibus Codes categorically classify the MyoPro 

orthosis as ‘Unproven’ [and] ‘not medically necessary.’”). Under the Omnibus Codes, “[t]he use 

of the upper limb orthotic known as the MyoPro orthosis is unproven and not medically necessary 

due to insufficient clinical evidence and/or efficacy in published peer-reviewed medical 

literature.” UHC 449. However, it is clear that the Omnibus Codes do not decisively resolve the 

issue of whether the MyoPro is medically necessary or unproven pursuant to the terms of the Plan.

Under Ninth Circuit precedent, “[a]n ERISA plan is a contract that we interpret ‘in an 

ordinary and popular sense as would a [person] of average intelligence and experience.’” See 

Harlick v. Blue Shield of California, 686 F.3d 699, 708 (9th Cir. 2012) (citation omitted). The 

Certificate of Coverage describes the Omnibus Codes as follows: “We have a process by which 

we compile and review clinical evidence with respect to certain health services. From time to 

time, we issue medical and drug policies that describe the clinical evidence available with respect 

to specific health care services. These medical and drug policies are subject to change without 

prior notice.” UHC 258.

By the terms of the Certificate of Coverage, then, the Omnibus Codes are only meant to 

“describe the clinical evidence available” as to a particular service. Id. Further, the Omnibus 

Codes themselves do not constitute binding terms of the Plan. The Omnibus Codes represent a 

“Medical Policy [that] provides assistance in interpreting [Defendant UHC’s] benefit plans.” 

UHC 353 (emphasis added). The Omnibus Codes dictate that “[w]hen deciding coverage, the 

member specific benefit plan document must be referenced.” Id. Indeed, the Omnibus Codes 

states that “[t]he terms of the member specific benefit plan document (e.g., Certificate of Coverage 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 28 of 41
29

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

(COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)) may differ greatly 

from the standard benefit plan upon which this Medical Policy is based.” Id. The Omnibus Codes 

also state that “[i]n the event of a conflict, the member specific benefit plan document supersedes 

this Medical Policy.” Id.

Accordingly, because the Omnibus Codes themselves do not constitute binding Plan terms, 

the fact that the Omnibus Codes categorize the MyoPro as subject to the “Unproven Service(s)” 

exclusion does not resolve the question of whether the MyoPro is in fact subject to the exclusion. 

Instead, the Court must examine the terms of the Certificate of Coverage and the evidence in the 

administrative record directly. 

2. There is a Genuine Issue of Material Fact as to Whether the “Unproven 

Service(s)” Exclusion Applies

The Court must now determine whether there is a genuine issue of material fact as to 

whether the “Unproven Service(s)” exclusion bars Plaintiff’s request for the MyoPro. In order to 

do so, the Court must first determine what the “Unproven Service(s)” exclusion means. For the 

reasons the Court discusses below, this task is surprisingly difficult in the instant case.

As an initial matter, the “Unproven Service(s)” exclusion contained within the Certificate 

of Coverage appears to contain a typographical error. Indeed, the Certificate of Coverage 

indicates that the “Unproven Service(s)” provision applies to “services, including medications, 

that are not effective for treatment of the medical condition and/or not to [sic] have a beneficial 

effect on health outcomes due to insufficient and inadequate clinical evidence from wellconducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed 

medical literature.” UHC 258. Defendant UHC inexplicably quotes this language, from precisely 

the same page of the administrative record, differently. According to Defendant UHC, “Unproven 

Service(s)” are defined as “services, including medications, that are determined not to be effective 

for treatment of the medical condition . . . .” UHC Mot. at 4 (quoting UHC 258) (emphasis 

added). On Plaintiff’s appeal of the benefit denial with Defendant UHC, Defendant UHC also 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 29 of 41
30

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

wrongly quoted the foregoing language in the notice to Plaintiff of the appeal’s denial. UHC 78. 

This discrepancy is troubling. However, because it is not clear whether the meaning is 

materially different under either formulation, because Plaintiff received notice of Defendant 

UHC’s formulation of the provision during the benefit process, and because Plaintiff does not 

argue that the distinction is significant here, the Court assumes for the sake of the instant motions 

that Defendant UHC’s formulation applies.

Even on Defendant UHC’s formulation, however, the language of the “Unproven 

Service(s)” exclusion is far from a model of clarity. Once again, according to Defendant UHC, 

the “Unproven Service(s)” exclusion applies for “services, including medications, that are 

determined not to be effective and/or not to have a beneficial effect on health outcomes due to 

insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or 

cohort studies in the prevailing published peer-reviewed medical literature.” UHC Mot. at 4.

As an initial matter, the “and/or” is ambiguous. Whether the requirement is conjunctive or 

disjunctive affects the scope of the exclusion. Because the Court must resolve any ambiguities in 

favor of Plaintiff, and because exclusions in insurance plans are construed narrowly, the Court 

concludes that Defendant UHC and Defendant MAXIMUS must show that the MyoPro may be 

“determined not to be effective and not to have a beneficial effect on health outcomes due to 

insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or 

cohort studies in the prevailing published peer-reviewed medical literature.” See, e.g., O’Neal v. 

Life Ins. Co. of North America, 10 F. Supp. 3d 1132, 1136 (D. Mont. 2014) (“Terms that are not 

defined by the plan (and other ambiguities) are to be construed against the drafter of the plan.”).

A further difficulty arises from the fact that the “Unproven Service(s)” exclusion requires 

Defendant UHC to determine that a treatment is “not . . . effective” and does not “have a 

beneficial effect on health outcomes,” based on “insufficient and inadequate clinical evidence.” 

This is subtly different from an exclusion that applied when it could not be determined that a 

particular treatment was effective or had a beneficial effect on health outcomes. 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 30 of 41
31

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

Defendant UHC appears to read the exclusion to apply when it could not be determined 

that a particular treatment was effective or had a beneficial effect on health outcomes. E.g., UHC 

Mot. at 9 (suggesting that Plaintiff must “identify [] published peer-reviewed medical literature 

that establishes the safety and/or efficacy of this device when used to treat Plaintiff’s condition”). 

However, the Court cannot rewrite the “Unproven Service(s)” exclusion for the benefit of 

Defendant UHC and Defendant MAXIMUS. As the United States Supreme Court has explained, 

“[t]he principle that contractual limitations provisions ordinarily should be enforced as written is 

especially appropriate when enforcing an ERISA plan.” Heimseshoff v. Hartford Life & Accident 

Ins. Co., 571 U.S. 99, 108 (2013).

The Court therefore construes the “Unproven Service(s)” exclusion to apply only when the 

outcome of qualifying studies affirmatively suggest that a treatment is ineffective and does not 

have a beneficial impact on health outcomes. This is a higher threshold than mere absence of 

evidence; by its terms, the exclusion instead requires the actual existence of evidence of 

ineffectiveness and lack of impact. This result is compelled by the principles of ERISA, which 

require the Court to construe exclusions narrowly, enforce Plan terms as written, and resolve 

ambiguities against the drafter. See Heimseshoff, 571 U.S. at 108 (explaining that ERISA terms 

should generally be enforced as written); Dowdy v. Metro. Life Ins. Co., 890 F.3d 802, 810 (9th 

Cir. 2018) (“Under general principles of insurance law, exclusions are construed narrowly.”); 

O’Neal v. Life Ins. Co. of North America, 10 F. Supp. 3d at 1136 (“Terms that are not defined by 

the plan (and other ambiguities) are to be construed against the drafter of the plan.”).

The Court must now determine whether there is a genuine issue of material fact as to 

whether Defendant UHC and Defendant MAXIMUS can demonstrate that the “Unproven 

Service(s)” exclusion applies. The Court concludes that there is a genuine issue of material fact

on this issue. 

Specifically, the Omnibus Codes survey three publications that are purportedly relevant to 

Plaintiff’s use of the MyoPro. The first publication concluded that “[a]dding MyoPro to 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 31 of 41
32

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

supervised therapy provided little to no additional benefit” for participants. UHC 449. Moreover, 

the second publication concluded that “myoelectric bracing may be more beneficial than 

[repetitive task practice] only in improving self-reported function and perceptions of overall 

recovery.” Id. These two publications, and the Omnibus Codes’ discussion of them, do constitute

evidence that the MyoPro has been “determined not to be effective and not to have a beneficial 

effect on health outcomes due to insufficient and inadequate clinical evidence from wellconducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed 

medical literature.” The existence and apparent conclusions of these studies produces a genuine 

issue of material fact as to the applicability of the “Unproven Service(s)” exception to Plaintiff’s 

desired use of the MyoPro. See, e.g., Esdale v. Am. Cmty. Mut. Ins. Co., 914 F. Supp. 270, 273 

(N.D. Ill. 1996) (“[D]efendant is only entitled to summary judgment if the undisputed facts are 

that OHTA deems the procedure to be experimental or investigational for the treatment of Stage II 

breast cancer, and facts are not undisputed based on the OHTA report.”).

On the other hand, Plaintiff contends that the two studies’ conclusions are flawed in 

various ways, and Plaintiff points to countervailing opinions of Dr. Brandon Green. E.g., MAX 

552 (criticizing studies cited by Omnibus Codes and conclusions drawn from studies). On a 

motion for summary judgment, however, the Court cannot evaluate credibility and weigh the 

evidence. These determinations must await a trial on the administrative record under Federal Rule 

of Civil Procedure 52. See, e.g., Bigham v. Liberty Life Assurance Co. of Boston, 148 F. Supp. 3d 

1159, 1162 (W.D. Wash. 2015) (“[W]hen applying the de novo standard in an ERISA benefits 

case, a trial on the administrative record, which permits the court to make factual findings, 

evaluate credibility, and weigh evidence, appears to be the appropriate proceeding to resolve the 

dispute.”); see also Lee v. Kaiser Found. Health Plan Long Term Disability Plan, 812 F. Supp. 2d 

1027, 1032 (N.D. Cal. 2011) (“De novo review on ERISA benefits claims is typically conducted 

as a bench trial under Rule 52.”). 

Because there is a genuine issue of material fact as to whether Defendant UHC and 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 32 of 41
33

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

Defendant MAXIMUS may prove the applicability of the “Unproven Service(s)” exclusion, the 

Court DENIES Plaintiff’s motion for partial summary judgment as to Plaintiff’s ERISA § 

502(a)(1)(B) claim. The Court also DENIES Defendant UHC’s and Defendant MAXIMUS’s 

motions for summary judgment as to Plaintiff’s ERISA § 502(a)(1)(B) claim. The Court now 

turns to Plaintiff’s ERISA § 502(a)(3) claim.

D. Breach of Fiduciary Duty

The Court now turns to Plaintiff’s claim under ERISA § 502(a)(3) for breach of fiduciary 

duty. “To establish an action for equitable relief under . . . 29 U.S.C. § 1132(a)(3), the defendant 

must be an ERISA fiduciary acting in its fiduciary capacity, and must violate ERISA-imposed 

fiduciary obligations.” Mathews v. Chevron Corp., 362 F.3d 1172, 1178 (9th Cir. 2004). In other 

words, the elements Plaintiff must prove to prevail on the claim under ERISA § 502(a)(3) for 

breach of fiduciary duty are as follows: (1) Defendant UHC and Defendant MAXIMUS were Plan 

fiduciaries; (2) Defendant UHC and Defendant MAXIMUS breached their fiduciary duties; and 

(3) the breach caused harm to Plaintiff. See LYMS, Inc. v. Millimaki, No. 08-CV-1210-GPC-NLS, 

2013 WL 1147534, at *9 (S.D. Cal. Mar. 19, 2013) (“To state a claim for breach of fiduciary duty 

under ERISA, Plaintiffs must establish that (1) Defendants were Plan fiduciaries, (2) Defendants 

breached their fiduciary duties, and (3) the breach caused harm to the Plaintiffs.” (citing Brosted v. 

Unum Life Ins. Co., 421 F.3d 459, 465 (7th Cir. 2005)).

Defendant UHC is a named fiduciary. Moreover, as discussed supra, Defendant 

MAXIMUS is a functional fiduciary. Accordingly, there is no genuine issue of material fact that

Plaintiff meets the first element as to both Defendant UHC and Defendant MAXIMUS. However, 

there is a genuine issue of material fact as to whether Plaintiff meets the remaining two elements. 

Plaintiff asserts that Defendant UHC and Defendant MAXIMUS breached their duties of due care 

and loyalty. The Court addresses each theory in turn. The Court then turns to arguments raised by 

Defendant UHC and Defendant MAXIMUS that they are entitled to summary judgment on 

Plaintiff’s breach of fiduciary duty claim to the extent the claim seeks an injunction and 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 33 of 41
34

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

restitution.

1. Breach of the Duty of Due Care

First, Plaintiff asserts that Defendant UHC and Defendant MAXIMUS breached the duty 

of due care. See 29 U.S.C. § 1104(a)(1)(B) (requiring that fiduciaries act “with the care, skill, 

prudence, and diligence under the circumstances then prevailing that a prudent man acting in a like 

capacity and familiar with such matters would use in the conduct of an enterprise of a like 

character and with like aims”). Plaintiff claims that “[i]n failing to act prudently, and in failing to 

act in accordance with the documents governing the Plan, UHC, . . . [and] Maximus . . . have 

violated their fiduciary duty of care.” FAC ¶ 81; see also 29 U.S.C. § 1104(a)(1)(D) (requiring 

that fiduciaries act “in accordance with the documents and instruments governing the plan”). The 

Court concluded supra that there is a genuine issue of material fact as to whether the Plan in fact 

covers MyoPro. Accordingly, Plaintiff’s theory that Defendant UHC and Defendant MAXIMUS 

breached the duty of due care because they “fail[ed] to act in accordance with the documents 

governing the Plan” must also survive summary judgment.

Plaintiff alleges a separate theory as to Defendant MAXIMUS. According to Plaintiff, 

Defendant MAXIMUS reversed denials of coverage of the MyoPro multiple times in the past. 

Plaintiff Mot. at 19. Two of these previous decisions are contained within the administrative 

record. MAX 609–26. The reviewers in those decisions examined the particular medical records 

of the patients in those cases and based their decisions on the specific features of those patients’ 

conditions. Id. For instance, one reviewer cited the fact that a patient suffered from “the 

physiological equivalent of an incomplete upper motor neuron lesion,” which made that patient’s 

condition similar to that of a stroke victim. MAX 616. Moreover, it is unclear whether either 

patient sought to use the MyoPro for daily, long-term use, as Plaintiff does here. MAX 609–26.

Thus, the Court cannot conclude as a matter of law that merely because Defendant 

MAXIMUS’s independent reviewers reached a different conclusion in cases that involved 

different patients, Defendant MAXIMUS breached the duty of due care in the instant case. 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 34 of 41
35

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

Further, Plaintiff’s harm appears to depend on the success of Plaintiff’s argument that the MyoPro 

is in fact covered by the Plan, and the Court has concluded that this question is subject to a 

genuine issue of material fact. See, e.g., Mullin v. Scottsdale Healthcare Corp. Long Term 

Disability Plan, No. CV-15-01547-PHX-DLR, 2016 WL 107838, at *3 (D. Ariz. Jan. 11, 2016) 

(explaining that plaintiff’s “breach of fiduciary duty claim depends on the success of her claim for 

wrongfully denied benefits; if she is unsuccessful on Count I, then Count II necessarily fails 

because she has not alleged separate and distinct harm”). Accordingly, summary judgment as to 

Plaintiff’s claim under ERISA § 502(a)(3) for breach of the duty of due care is inappropriate

because there is a genuine issue of material fact as to whether Plaintiff can satisfy the second

element (breach of duty of due care) and third element (harm to Plaintiff) of the claim under 

ERISA § 502(a)(3) for breach of the duty of due care. The Court now addresses Plaintiff’s theory

as to breach of the duty of loyalty.

2. Breach of the Duty of Loyalty

Plaintiff also alleges that Defendant UHC and Defendant MAXIMUS breached the duty of 

loyalty. See 29 U.S.C. § 1104(a)(1)(A) (requiring that fiduciaries act “for the exclusive purposes 

of[] providing benefits to participants and their beneficiaries[] and defraying reasonable expenses 

of administering the plan”). Plaintiff’s theory as to the breach of the duty of loyalty is similar to 

Plaintiff’s theory as to the breach of the duty of due care. Specifically, according to Plaintiff, 

Defendant “UHC, . . . [and Defendant] Maximus . . . have violated their fiduciary duty of loyalty 

to [Plaintiff] by, among other things, refusing to cover the Myomo MyoPro, which costs in excess 

of $80,000, to their own advantage, at the expense of the Plan’s participants and beneficiaries.”

FAC ¶ 89. Plaintiff further claims that the Omnibus Codes constitute a “blanket policy” adopted 

by Defendant UHC to avoid coverage of the MyoPro. Plaintiff Mot. at 16.

As an initial matter, as discussed supra, the Omnibus Codes do not impose binding terms 

on Defendant UHC. Instead, the Omnibus Codes represent a “Medical Policy [that] provides 

assistance in interpreting [Defendant UHC’s] benefit plans.” UHC 353 (emphasis added). The 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 35 of 41
36

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

Omnibus Codes dictate that “[w]hen deciding coverage, the member specific benefit plan 

document must be referenced.” Id. Indeed, the Omnibus Codes state that “[t]he terms of the 

member specific benefit plan document (e.g., Certificate of Coverage (COC), Schedule of Benefits 

(SOB), and/or Summary Plan Description (SPD)) may differ greatly from the standard benefit 

plan upon which this Medical Policy is based.” Id. The Omnibus Codes also state that “[i]n the 

event of a conflict, the member specific benefit plan document supersedes this Medical Policy.” 

Id. On their own terms, then, the Omnibus Codes do not prove the existence of a “blanket policy” 

adopted by Defendant UHC.

Further, it is true that Defendant UHC and Defendant MAXIMUS did not cover the 

MyoPro in the instant case, or in Plans with the same terms as the ones that govern the instant 

case. However, the Court has concluded that there is a genuine issue of material fact as to whether 

the Plan covers Plaintiff’s request for the MyoPro in the first place. Thus, there is a genuine 

dispute of material fact as to whether Defendants breached their duty of loyalty and whether 

Plaintiff suffered resulting harm. Because there is a genuine dispute of material fact as to the 

second element (breach of duty of loyalty) and the third element (harm to Plaintiff) of Plaintiff’s 

claim under ERISA § 502(a)(3) for breach of the duty of loyalty, summary judgment on this claim

is inappropriate. See, e.g., Mullin, 2016 WL 107838, at *3 (explaining that plaintiff’s “breach of 

fiduciary duty claim depends on the success of her claim for wrongfully denied benefits; if she is 

unsuccessful on Count I, then Count II necessarily fails because she has not alleged separate and 

distinct harm”). 

The Court now turns to arguments raised by Defendant UHC and Defendant MAXIMUS 

that they are entitled to summary judgment on Plaintiff’s breach of fiduciary duty claim to the 

extent the claim seeks an injunction and restitution.

3. Availability of an Injunction and Restitution

Defendant UHC contends that Plaintiff’s claim under ERISA § 502(a)(3) to the extent it 

seeks an injunction against Defendant UHC must be denied as a matter of law. First, Defendant 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 36 of 41
37

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

UHC contends that such an injunction is duplicative of the relief Plaintiff seeks under ERISA § 

502(a)(1)(B). UHC Opp’n at 8. However, in Moyle v. Liberty Mut. Retirement Ben. Plan, the 

Ninth Circuit explained that a plaintiff could plead alternative theories of recovery under ERISA § 

502(a)(1)(B) and ERISA § 502(a)(3), so long as the plaintiff does not ultimately “obtain[] double 

recoveries.” 823 F.3d 948, 960 (9th Cir. 2016). The authorities cited by Defendant UHC are no 

longer good law to the extent they hold otherwise. See id. at 962 (“Some of our pre-Amara cases 

held that litigants may not seek equitable remedies under § 1132(a)(3) if § 1132(a)(1)(B) provides 

adequate relief. . . . However, those cases are now ‘clearly irreconcilable’ with Amara and are no 

longer binding.”). In the instant case, Plaintiff will be unable to obtain double recovery under 

ERISA § 502(a)(1)(B) and ERISA § 502(a)(3), but that does not mean that Defendant UHC is 

entitled to judgment as a matter of law on Plaintiff’s ERISA § 502(a)(3) claim.

The arguments of Defendant UHC and Defendant MAXIMUS as to the scope of a 

potential injunction are similarly premature, as the appropriate scope of an injunction depends on 

which facts Plaintiff successfully proves after a trial on the administrative record. The Court will 

narrowly tailor any injunctive relief to which Plaintiff is entitled. See, e.g., Nat. Resources Def. 

Council, Inc. v. Winter, 508 F.3d 885, 886 (9th Cir. 2007) (explaining that “injunctive relief must 

be tailored to remedy” harm in particular case).

However, Defendant MAXIMUS also argues that Plaintiff’s request for restitution under 

ERISA § 502(a)(3) fails as a matter of law. The Court agrees. Compensatory damages are 

unavailable under ERISA § 502(a)(3). See Mertens v. Hewitt Assocs., 508 U.S. 248, 259 (1993) 

(explaining that legal remedies such as compensatory damages are unavailable ERISA § 

502(a)(3)). Here, while Plaintiff appears to seek restitution under ERISA § 502(a)(3), the Ninth 

Circuit has repeatedly drawn a distinction between restitution at law and restitution at equity. See, 

e.g., Depot, Inc. v. Caring for Montanans, Inc., 915 F.3d 643, 662 (9th Cir. 2019) (outlining 

distinction). Only restitution at equity is available under ERISA § 502(a)(3). Id. at 661. Plaintiff 

does not specify whether Plaintiff seeks restitution at law or restitution at equity. Instead, Plaintiff 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 37 of 41
38

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

generically seeks “restitution for reimbursements improperly withheld by Defendants.” FAC at 28.

Under Ninth Circuit case law, this relief amounts to restitution at law because it would require 

Defendant UHC and Defendant MAXIMUS “to pay a certain amount of money, and they could 

satisfy that obligation by dipping into any pot they like.” Depot, Inc., 915 F.3d at 662 (internal 

quotation marks omitted). Accordingly, to the extent Plaintiff seeks restitution under ERISA § 

502(a)(3), this form of relief is barred. 

In sum, the Court DENIES Plaintiff’s motion for partial summary judgment as to 

Plaintiff’s claim for breach of fiduciary duty under ERISA § 502(a)(3). The Court also DENIES 

Defendant UHC’s and Defendant MAXIMUS’s motions for summary judgment to the extent that 

Plaintiff’s claim for breach of fiduciary duty under ERISA § 502(a)(3) seeks injunctive relief. The 

Court GRANTS Defendant UHC’s and Defendant MAXIMUS’s motions for summary judgment 

to the extent that Plaintiff’s claim for breach of fiduciary duty under ERISA § 502(a)(3) seeks 

restitution. The Court now turns to Plaintiff’s final claim, a claim for denial of a full and fair 

review under ERISA § 503.

E. Denial of Full and Fair Review under ERISA § 503

Finally, Defendant UHC and Defendant MAXIMUS both move for summary judgment as 

to Plaintiff’s claim that Defendant UHC and Defendant MAXIMUS deprived Plaintiff of a full 

and fair review. The Court agrees that summary judgment as to this claim is appropriate.

Under ERISA § 503, all adverse benefit determinations must:

(1) provide adequate notice in writing to any participant or beneficiary whose claim 

for benefits under the plan has been denied, setting forth the specific reasons for 

such denial, written in a manner calculated to be understood by the participant, 

and

(2) afford a reasonable opportunity to any participant whose claim for benefits has 

been denied for a full and fair review by the appropriate named fiduciary of the 

decision denying the claim.

29 U.S.C. § 1133. The operative regulations further state that ERISA plans must: (i) provide 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 38 of 41
39

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

claimants at least 60 days following receipt of a notification of an adverse benefit determination 

within which to appeal the determination; (ii) provide claimants the opportunity to submit written 

comments, documents, records, and other information relating to the claim for benefits; (iii) 

provide that a claimant shall be provided, upon request and free of charge, reasonable access to, 

and copies of, all documents, records, and other information relevant to the claimant’s claim for 

benefits; (iv) provide for a review that takes into account all comments, documents, records, and 

other information submitted by the claimant relating to the claim, without regard to whether such 

information was submitted or considered in the initial benefit determination. 29 C.F.R. § 2560-

503.1(h)(2)(i)–(iv).

As an initial matter, Defendant MAXIMUS argues that Defendant MAXIMUS’s conduct 

cannot fall within the scope of ERISA § 503 because Defendant MAXIMUS is not a “named 

fiduciary.” MAXIMUS Mot. at 9. Plaintiff fails to respond to this argument. Thus, the Court 

finds summary judgment appropriate as to this claim against Defendant MAXIMUS. See 

Sandoval v. Los Angeles Cnty., No. CV 90-3428 PSG (SSx), 2010 WL 11545547, at *11 (C.D. 

Cal. April 4, 2010) (noting that failure to address an argument in response to motion for summary 

judgment waives opposition to it); see also Wade v. Life Ins. Co. N.A., 245 F. Supp. 2d 182, 190 

(D. Me. 2003) (“Moreover, the very statute upon which Plaintiff bases her argument only entitles 

her to a review by ‘the appropriate named fiduciary,’ 29 U.S.C. § 1133(2), not a full and fair 

review by outside arbitrators.”).

Next, Plaintiff argues that Defendant UHC denied Plaintiff a full and fair review in three 

different ways. First, Plaintiff claims that Defendant “UHC was obligated to conduct a second 

level appeal after it denied [Plaintiff’s] first level appeal.” Plaintiff First Opp’n at 10. However, 

the Certificate of Coverage does not contain any such guarantee. Instead, the Certificate of 

Coverage contemplates that the second appeal take the form of an independent medical review in 

qualifying categories. UHC 228. Defendant UHC informed Plaintiff of the right to undertake an 

independent medical review throughout the process, and Plaintiff ultimately availed himself of the 

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 39 of 41
40

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

independent medical review. E.g., UHC 38.

Second, Plaintiff contends that Defendant “UHC failed to allow [Plaintiff] to address the 

claim the MyoPro is ‘Unproven’ as stated in the Omnibus Codes before denying his appeal.” 

Plaintiff First Opp’n at 10. Such an argument may constitute another theory of breach of fiduciary 

duty. See 29 U.S.C. § 1104(a)(1)(D) (requiring that fiduciaries act “in accordance with the 

documents and instruments governing the plan”). However, alleged failure to obey the terms of 

the Plan does not comprise a separate claim under ERISA § 503. See 29 C.F.R. § 2560-

503.1(h)(2)(i)–(iv) (outlining requirements).

Third, and finally, Plaintiff argues that “the initial claim and appeal do not appear to have 

been conducted by competent individuals.” Plaintiff First Opp’n at 10. Again, Plaintiff attempts 

to repackage a theory of breach of fiduciary duty as a denial of full and fair review. See 29 U.S.C. 

§ 1104(a)(1)(B) (requiring that fiduciaries act “with the care, skill, prudence, and diligence under 

the circumstances then prevailing that a prudent man acting in a like capacity and familiar with 

such matters would use in the conduct of an enterprise of a like character and with like aims”). 

Plaintiff may seek equitable relief under ERISA § 502(a)(3) pursuant to Plaintiff’s breach of 

fiduciary duty claim that can sufficiently resolve these alleged deficiencies.

Accordingly, the Court GRANTS Defendant UHC’s and Defendant MAXIMUS’s motions

for summary judgment as to Plaintiff’s claim for denial of a full and fair review under ERISA § 

503.

IV. CONCLUSION

For the foregoing reasons, the Court DENIES Plaintiff’s motion for partial summary 

judgment. The Court also rules on the motions for summary judgment of Defendant UHC and

Defendant MAXIMUS as follows:

• The Court DENIES the motions for summary judgment of Defendant UHC and 

Defendant MAXIMUS as to Plaintiff’s claim for improper denial of benefits under 

ERISA § 502(a)(1)(B);

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 40 of 41
41

Case No. 18-CV-07454-LHK 

ORDER DENYING PLAINTIFF’S MOTION FOR PARTIAL SUMMARY JUDGMENT; GRANTING IN PART 

DEFENDANT UHC’S MOTION FOR SUMMARY JUDGMENT; GRANTING IN PART DEFENDANT 

MAXIMUS’S MOTION FOR SUMMARY JUDGMENT

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

United States District Court

Northern District of California

• The Court GRANTS the motions for summary judgment of Defendant UHC and 

Defendant MAXIMUS as to Plaintiff’s claim for breach of fiduciary duty under 

ERISA § 502(a)(3) to the extent that it seeks restitution; 

• The Court DENIES the motions for summary judgment of Defendant UHC and 

Defendant MAXIMUS as to Plaintiff’s claim for breach of fiduciary duty under 

ERISA § 502(a)(3) to the extent that it seeks injunctive relief;

• The Court GRANTS the motions for summary judgment of Defendant UHC and 

Defendant MAXIMUS as to Plaintiff’s claim for denial of a full and fair review 

under ERISA § 503.

Thus, the parties shall proceed to trial on Plaintiff’s claim for improper denial of benefits under 

ERISA § 502(a)(1)(B), and Plaintiff’s claim for breach of fiduciary duty under ERISA 502(a)(3) 

to the extent that it seeks injunctive relief. 

IT IS SO ORDERED.

Dated: April 8, 2020

______________________________________

LUCY H. KOH

United States District Judge

Case 5:18-cv-07454-LHK Document 181 Filed 04/08/20 Page 41 of 41