In Condry v. UnitedHealth Grp., Inc., No. 20-16823, __F.App’x__, 2021 WL 4225536 (9th Cir. Sept. 16, 2021), a now partially settled class action dispute over the payment of out-of-network lactation services brought under the Affordable Care Act (ACA) and ERISA, the Ninth Circuit ruled on cross-appeals challenging six district court rulings.
First, the court determined that it did not have jurisdiction to review Intervenor-Plaintiff Teresa Harris’s motion for permissive intervention because the district court did not abuse its discretion when it determined that granting Harris’s motion to intervene would unfair prejudice UnitedHealth Group Inc. (“United”). The court also found lack of jurisdiction to review the district court’s denial of her motion for intervention as a matter of right because she did not timely appeal (waiting about nine months after the district court denied her motion).
Second, the court affirmed the district court’s grant of summary judgment to United on Plaintiffs Rachel Condry’s and Felicity Barber’s reimbursement claims because under the applicable ACA regulations, “plan administrators that offer participants access to in-network lactation-services providers are not required to cover lactation services that are provided by an out-of-network provider. 29 C.F.R. § 2590.715-2713(a)(3)(i).” It is undisputed that the plaintiffs sought care from out-of-network providers when there were in-network providers nearby.
Third, the district court did not have Article III jurisdiction over Condry’s and Barber’s full-and-fair review claims based on United’s alleged failure to comply with ERISA’s claims-processing rules when United sent allegedly confusing explanations for the denial of their requests for reimbursement. Because the plaintiffs are not entitled to any reimbursement from United under the ACA, a ruling in their favor on their full-and-fair-review claim could not redress any concrete injury. Specifically, “a ruling in favor of Condry and Barber on their full-and-fair-review claims and an order directing United to send them a clearer denial letter could not possibly lead to reimbursement.” The court vacated the district court’s grant of summary judgment to plaintiffs on these claims and remanded with instructions to dismiss those claims for lack of standing.
Fourth, the court determined that the parties’ partial settlement mooted the full-and-fair-review claims of Plaintiffs Bishop, Hoy, and Endicott. United agreed to reimburse Hoy and Bishop for the cost of out-of-network lactation services and settled Endicott’s claim. Because their claims became moot during the course of the litigation, the court vacated the district court’s grant of summary judgment to hem on their full-and-fair-review claims and remanded with instructions to discuss those claims as moot.
Fifth, the court reversed the district court’s grant of class certification to the “Denial Letter Class” and dismissed the Denial Letter Class claim. The court found that the class was not properly certified because the district court applied the incorrect legal standard for determining whether United complied with ERISA’s claim-processing rules. Under Ninth Circuit precedent, courts must consider the entire course of communication between a plan administration and ERISA plan participant to determine whether a denial letter provided sufficiently clear explanations for the denial of benefits. Because of this necessary individualized inquiry, the class representatives’ claims are not typical of the class members’ claims. The district court erred by focusing exclusively on the remark codes that United used in its denial letters. Because the Denial Letter Class was not properly certified before the partial settlement agreement, the class claim must be dismissed as moot. The court vacated the grant of permanent injunctive relief in favor of the Denial Letter Class.
Sixth, the court dismissed the Claims Reprocessing Class claim as moot. The court found that the district court did not abuse its discretion when it denied class certification: “As the district court correctly recognized, United did not take a uniform approach to resolving claims for out-of-network comprehensive lactation services. The claims of the named plaintiffs thus are not typical of the claims of the class, as they must be for class certification.” Since the court denied class certification before the plaintiffs’ claims became moot due to settlement, the class claim must also be dismissed as moot.
*Please note that this blog is a summary of a reported legal decision and does not constitute legal advice. This blog has not been updated to note any subsequent change in status, including whether a decision is reconsidered or vacated. The case above was handled by other law firms, but if you have questions about how the developing law impacts your ERISA benefit claim, the attorneys at Roberts Disability Law, P.C. may be able to advise you so please contact us.
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