The Med. Soc'y of the State of N.Y. v. UnitedHealth Grp. Inc.

ERISA Not Violated by United's Denial of 'Facility Fees' for Doctor Office-Based Surgeries

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FINDINGS OF FACT AND CONCLUSIONS OF LAW The central issue in this class action is whether a health insurer violated ERISA (the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§1001, et seq.) when it determined that physicians performing office-based surgeries in the state of New York are not entitled to a “facility fee.” Plaintiffs are two organizations — the Medical Society of the State of New York (“MSSNY”) and the Society of New York Office Based Surgery Facilities (“NYOBS”) — and a Manhattan medical practice, Columbia East Side Surgery, P.C. (“Columbia East Side”). Defendants are UnitedHealth Group Inc., United HealthCare Services, Inc., United HealthCare Insurance Company, United HealthCare Service LLC, Optum Group, LLC, Optum, Inc., and Oxford Health Plans LLC (collectively, “United”). A five-day bench trial was held before this Court in February 2022. The parties subsequently filed post-trial briefs and response briefs. (See Dkt. Nos. 349, 352, 355, 359.) The Court now issues its Findings of Fact and Conclusions of Law pursuant to Rule 52(a) of the Federal Rules of Civil Procedure. The Court assumes familiarity with the background of this case and the legal conclusions set forth in the Court’s prior opinions, which are deemed incorporated herein. (See Dkt. Nos. 59, 87, 153, 204, 214, 215, 289.) I. Findings of Fact A. Background for Adjudicating Claims 1. United’s Processes for Drafting and Vetting Plan Language United administers ERISA-governed health benefit plans. While some of these plans are fully insured, the majority are self-funded, which means that the plan sponsor pays any benefits and United acts only as a third-party administrator (known as “Administrative Services Only” or “ASO” plans). (Stip.

7, 21, 23.) A Certificate of Coverage (“COC”) governs fully insured plans and the terms of the ASO plans are described in a Summary Plan Description (“SPD”). (Stip.

The Med. Soc'y of the State of N.Y. v. UnitedHealth Grp. Inc.

ERISA Not Violated by United's Denial of 'Facility Fees' for Doctor Office-Based Surgeries

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