Condry v. UnitedHealth Group Inc.,et.al

Background

The plaintiffs sought certification of classes involving coverage for out-of-network lactation services. The opinion states that, at summary judgment, the court ruled that United Healthcare violated the Employee Retirement Income Security Act (ERISA) requirement that a benefit-denial letter be written in a way the claimant could understand. The proposed classes also concerned whether United Healthcare improperly denied coverage required by the Affordable Care Act when in-network lactation services were unavailable.

Denial-Letter Class

The court granted certification of a class of ERISA plan participants who received the same denial letters as the five named plaintiffs. The proposed remedy was an order requiring United Healthcare to send class members new letters explaining the basis for the denials in understandable terms.

The court held that later communications might have resolved some participants’ benefit disputes or made the original denial understandable, but those communications did not change the alleged fact that United Healthcare sent the same type of incomprehensible letter to each class member. The court certified this class under Federal Rule of Civil Procedure 23(b)(2). It directed the parties to submit an agreed draft follow-up letter with their next case-management statement, or competing drafts if they could not agree after a good-faith effort.

Claims-Reprocessing Classes

The court denied the request to certify nationwide classes seeking an order requiring United Healthcare to reprocess claims under the correct standard. The plaintiffs had proposed two related classes: people in ERISA plans whose claims were denied and people in non-ERISA plans whose claims were denied. The court discussed them together because the issues were the same.

The court identified several problems with the proposed classes. First, the proposal included both people who submitted claims and were denied and people who received out-of-network services but never submitted claims. The named plaintiffs all belonged to the first group, and the court found that the two groups would present different liability questions.

Second, the evidence did not establish that United Healthcare applied one uniform standard or practice to the denied claims. The plaintiffs’ data showed that approximately 88 percent of identified out-of-network lactation claims were partially or fully denied while approximately 12 percent were fully granted. The plaintiffs did not provide sufficient evidence explaining the split or showing that all claims had been evaluated without regard to whether in-network services were available.

The court identified several possible explanations for the different results, including participants’ use of plan procedures for obtaining out-of-network approval, differences in whether in-network services were available, and differences in whether participants sought approval before receiving care. The record did not show how many proposed class members fit into each category.

The court also found that the proposed nationwide class included participants in different health plans, employer plans, and geographic regions, while the parties had provided documents for only some plans. The evidence therefore did not establish that participants had experienced the same standard or practice. The court acknowledged evidence that United Healthcare had performed poorly in complying with the Affordable Care Act and communicating with members, but held that the plaintiffs had not shown that the pre-approval mechanisms were uniformly inadequate or that the alleged noncompliance was uniform nationwide.

Other Rulings and Disposition

The court stated that none of the named plaintiffs had standing to seek prospective injunctive relief, relying on an earlier ruling. It therefore addressed the plaintiffs’ request for a claims-reprocessing class rather than a class seeking prospective reforms.

The court granted in part and denied in part the motion for class certification. It certified the denial-letter class and denied certification of the claims-reprocessing class. The court also granted United Healthcare’s administrative motion to file portions of an exhibit under seal. It denied as moot the motions to exclude experts Hanley, McGlone, and Morton. Judge Vince Chhabria scheduled a case-management conference for January 22, 2020, and required a joint case-management statement by January 15, 2020.