# Evans v. UnitedHealthcare of Oklahoma Inc.

> District Court, N.D. Oklahoma · February 2, 2022

URL: https://www.frixlaw.com/law-library/cases/10386820

## Case

- **Court:** District Court, N.D. Oklahoma
- **Decided:** February 2, 2022
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

- No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases.
- Full citator and citing cases: https://www.frixlaw.com/law-library/cases/10386820

## How later opinions describe it (automated extraction)

- applying a deferential standard of review when the plan administrator or fiduciary has discretionary authority to determine eligibility for benefits or to construe the terms of a plan
- concluding that a remand for further findings or explanations is the proper remedy where a plan administrator’s decision was so one-sided that the court was unable to determine the 10 substantiality of the evidence supporting the benefits determination

## Opinion text

UNITED STATES DISTRICT COURT FOR THE
NORTHERN DISTRICT OF OKLAHOMA
EDITH EVANS, )
)
Plaintiff, )
)
v. ) Case No. 20-CV-0670-CVE-SH
)
UNITED HEALTHCARE OF OKLAHOMA )
INC., an Oklahoma Corporation, )
)
)
Defendant. )
OPINION AND ORDER
Plaintiff filed this action seeking, inter alia, to recover benefits and enforce her rights under
the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1101 et seq. (ERISA).
Specifically, this action arises from United Healthcare of Oklahoma Inc. (UHC) denying benefits
as to payment for hospital services that plaintiff received after undergoing a breast reconstruction
procedure. Before the Court are plaintiff’s opening brief (Dkt. # 61), defendant’s response (Dkt. #
70), plaintiff’s reply (Dkt. # 71), defendant’s counterclaim for attorneys’ fees (Dkt. # 37, at 9), and
plaintiff’s motion to dismiss, strike, or clarify defendant’s counterclaim (Dkt. # 40). Plaintiff argues
that defendant’s denial should be reversed because defendant 1) interpreted the terms of plaintiff’s
insurance plan unreasonably; 2) did not base its denial on substantial evidence; and 3) “failed to
provide [p]laintiff with adequate notice of its denial and failed to provide [p]laintiff with a full and
fair review . . . [thereby] violat[ing] ERISA procedural safeguards[.]” Dkt. # 61, at 7. Defendant
responds that “its denial of the subject claim was not an abuse of discretion and was the correct,
reasonable determination and is supported by substantial evidence.” Dkt. # 70, at 7.
I.
Plaintiff, Edith Evans, is a 61-year-old woman who battled breast cancer for
years–undergoing radiation treatment and several surgical procedures, including a bilateral
mastectomy and breast reconstruction surgeries. Dkt. # 61, at 5. Plaintiff is an insured beneficiary

under a UHC employee benefit plan (the plan), group policy number 909377, governed by ERISA.
Dkt. # 70, at 6. Per the policy, UHC is the “Plan’s Claims Fiduciary and has been delegated”
discretionary authority to interpret terms of the plan and make eligibility determinations. Dkt. # 49-
1, at 174.
On May 11, 2017, prior to her bilateral mastectomy, UHC informed plaintiff in writing that
it “reviewed [her] request for Outpatient Facility services . . . and found that the [mastectomy
procedures] are eligible for Outpatient Facility coverage.” Id. at 177. UHC’s written confirmation
stated that this eligibility determination was copied to Dr. Thomas Coy and Freeman Health System

(Freeman). Id. at 178. Accordingly, on May 19, 2017, Dr. Coy, an in-network physician, performed
plaintiff’s bilateral mastectomy at Freeman, an in-network facility. Id. at 192, 319. On May 25,
2017, Freeman submitted a claim for reimbursement to UHC for plaintiff’s procedures. Id. at 182-
90. On June 8, 2017, UHC sent plaintiff an Explanation of Benefits (EOB) statement informing her
of Freeman’s billed amount, UHC’s payment amount, and that plaintiff owed $0. Id. at 197-200.
The record also includes UHC’s June 13, 2017 “Provider Remittance Advice” (PRA) statement that
it sent to Freeman, which contains an itemized list of Freeman’s submitted charges, any adjustment
amount, and the amount UHC paid. Id. at 205-14. The statement indicates that UHC paid Freeman
$4048.50, and plaintiff was subsequently sent an updated EOB statement, on June 22, 2017,

reflecting a $4048.50 adjustment. Id. at 215.
2
According to the administrative record (Dkt. # 49-1), Freeman requested a review and
reprocessing of its claim related to plaintiff’s May 19, 2017 surgery, and the review request was
logged in UHC’s “online routing system” (ORS). Id. at 235-39. UHC’s date-stamped ORS log
includes plaintiff’s name and group policy number; date of service; date of appeal; reason for appeal;

the name of a Freeman employee contact; the name of the provider; whether the provider was in-
network or out-of-network; what was “wrong” with the claim that was denied; when the appeal
“record” was opened or assigned to a particular UHC administrator, and so forth. Id. at 235-36.
After plaintiff’s 2017 mastectomy, she “required two invasive breast reconstructive
surgeries” due to severe tissue damage from cancer treatment. Dkt. # 61, at 5. The first
reconstructive surgery, which is the subject of the instant case, was performed on February 14, 2018
by Dr. William Hughes, an in-network physician with an office in Mercy Clinic, at Mercy Hospital-
Springfield (Mercy Hospital), an out-of-network facility. Id. at 5, 13. Further, the agreed
supplemental administrative record (Dkt. # 57) contains what appears to be a doctor’s note, dated

January 19, 2018, with plaintiff’s name, the date of her first scheduled reconstructive surgery
(February 14, 2018), a list of procedures with procedure codes, the words “Springfield,” “Main
OR,”1 and “UHC.” Dkt. # 57, at 8. Importantly, the doctor’s note appears to have a post-it note or
stamp affixed to it (hereinafter the insurance verification note). Id. This insurance verification note,
dated January 24, 2018, as completed, states: “Insurance Verification”; the name “Susan” under
“Contact”; and contains hand-written information, specific to plaintiff’s group policy, such as her
deductible, out-of-pocket (OOP) maximum, and co-insurance structure, compare Dkt. # 57, at 8,

1 As used throughout the administrative record and herein, it is assumed that “OR” means
operating room.
3
with Dkt. # 49-1, at 27-29, 33. The handwritten insurance verification note further states “in-
net[work] only”; “Mercy & Dr. H[ughes] are in-net[work]”2; and “no auth[orization] needed per
codes due to Br[east] CA[ncer] D[iagnosis].” Dkt. # 57, at 8.
On February 14, 2018, plaintiff underwent the breast reconstruction surgery at Mercy

Hospital, performed by Dr. Hughes. Dkt. # 49-1, at 240-43. Plaintiff recovered at Mercy Hospital,
and was discharged on February 15, 2018. Id. at 253. On February 20, 2018, Mercy Clinic
Springfield submitted a claim for $11,897 for Dr. Hughes’s services. Id. at 240-44. The claim
contained three charges related to surgery, and the procedure codes “19361" and “LT” (left side);
“19357" and “RT” (right side); and “19340" and “LT.” Id. at 242. The procedure codes on Mercy
Clinic’s February 20, 2018 claim match the procedure codes written on the January 24, 2018
insurance verification note. Compare Dkt. # 49-1, at 242, with Dkt. # 57, at 8. On February 23,
2018, UHC sent plaintiff an EOB statement, which included the claim for Dr. Hughes, and the
accompanying notes acknowledging Dr. Hughes’s in-network status. Dkt. # 49-1, at 247-48 (“the

plan discount shown is your savings for using a network provider”). UHC paid the provider
$2,174.17 and, based on her remaining deductible and co-insurance, plaintiff owed $1,054.71 for
that claim. Id.
Mercy Hospital filed a separate claim on February 26, 2018, billing $51,059.68 for hospital
services such as room and board, surgical supplies, sterile supplies, and OR services. Id. at 252-55.
On March 8, 2018, UHC sent plaintiff an EOB statement indicating that UHC did not pay any

2 The Court notes that it appears, at bottom, there was a miscommunication somewhere
between Dr. Hughes’s office among Mercy Clinic, Mercy Hospital-Springfield, and
UHC–perhaps because some of Mercy Hospital’s facilities are in-network and some are out-
of-network.
4
portion of the $51,059.68 Mercy Hospital bill. Id. at 256-58. The EOB notes accompanying the
Mercy Hospital benefits denial state:
Based on the information provided, this service does not meet coverage requirements as
defined in your plan. Therefore, no benefits are payable for this expense. In order for this
service to be considered for coverage, you or your medical provider must submit either
scientific evidence, skilled care information or medical records that demonstrate how this
service meets the requirements indicated in your benefit plan language.
Id. at 257-58.
According to the agreed supplemental record (Dkt. # 57), Mercy Hospital submitted a
“Single Claim Reconsideration Request Form” to UHC on behalf of plaintiff, and attached a letter
in support dated March 28, 2018. Dkt. # 57, at 9, 6-7. On the reconsideration request form, Mercy
Hospital appeals nurse, Sheri Noble, selected “[o]ther” under “[r]eason for request[,]” and stated
“[a]pproved as SOEC,3 but we billed appropriately as inpatient” and “[s]ee appeal letter[.]” Id. at
9. In the appeal letter, Ms. Noble states that “[n]o authorization was required, but a reference
number was given: 111691701[.]” Id. at 6. The letter further states that Mercy Hospital “request[s]
an appeal in response to the denial applied to the hospital services for [plaintiff].” Id. “The
insurance indicates the denial is for lack of medical necessity for inpatient”;4 however, “[a]
latissimus flap is inpatient and since we notified you that this was inpatient on 2/15/18 and you

3 It is unclear what SOEC stands for--perhaps an abbreviation related to an outpatient
procedure.
4 Based on the reconsideration request form (Dkt. # 57, at 9) and the attached appeal letter
(Dkt. # 57, at 6-7), it appears that there is not only confusion about whether Mercy Hospital
called UHC for precertification, but also confusion as to whether UHC had approved the
procedure as outpatient rather than inpatient. Thus, it appears that because of Mercy
Hospital’s confusion and miscommunication with UHC, the appeal focuses on the medical
necessity for plaintiff’s inpatient stay rather than whether Mercy Hospital notified UHC in
advance about plaintiff undergoing the procedure at its Springfield facility.
5
never responded to our request, we must assume that this is approved because our agreement with
UHC is that if there is a disagreement over the status, that UHC will contact [us].” Id. Then, in a
different sentence, Ms. Noble states: “[w]hen we called for precert[ification] we were told that none
was needed because of [plaintiff’s] previous breast cancer diagnosis.” Id. at 7.

On April 5, 2018, UHC sent Mercy Hospital a letter acknowledging that it “received a letter
sent on [Mercy Hospital’s] behalf in the UnitedHealthcare Central Escalation Unit. If [Mercy
Hospital’s] request qualifies for an appeal, grievance, or complaint, [UHC] will complete [its]
review and send [Mercy Hospital] a letter about [its] decision[.]” Dkt. # 49-1, at 263. While the
administrative record contains UHC’s acknowledgment letter (Dkt. # 49-1, at 263) stating that it
received Mercy Hospital’s appeal letter, the appeal letter itself is not included in the administrative
record that was initially submitted to the Court (Dkt. # 49-1); however, it is included in the agreed
supplemental administrative record (Dkt. # 57, at 6-7). Consequently, on April 20, 2018, UHC
informed Mercy Hospital that it “reviewed [Mercy Hopital’s] request about the [February 14, 2018]

claim for [plaintiff]. Based on [UHC’s] review, [it] determined that [UHC] processed the claim
accurately. No further payment is due because the claim was processed/paid at the contracted rate.”
Dkt. # 49-1, at 265.
Mercy Hospital re-submitted its claim to UHC on September 11, 2018, billing $51,011.20
for hospital services. Id. at 266-67. Additionally, the administrative record shows that Mercy
Hospital re-submitted the claim a third time, for $49,546.59, on September 19, 2018. Id. at 270-74.
Unlike the February 26, 2018 (Dkt. # 49-1, at 253) and September 11, 2018 (Dkt. # 49-1, at 267)
claims, the September 19, 2018 claim (Dkt. # 49-1, at 271) itemizes “OR services” into three

separate line items, with procedure codes “19361" and “LT”; “19340" and “LT”; and “”19357" and
6
“RT.” These procedure codes match the procedure codes written on the January 24, 2018 insurance
verification note. Compare Dkt. # 49-1, at 271, with Dkt. # 57, at 8.
Thereafter, UHC sent plaintiff an EOB statement on September 25, 2018, which includes
Mercy Hospital’s $49,546.59 bill for hospital services, and again paid nothing for the Mercy

Hospital claim. Dkt. # 49-1, at 275-76. The EOB notes accompanying UHC’s denial of Mercy
Hospital’s claim state:
Benefits for this service are denied. Based on a review of the information provided, this
service is not covered under your plan. For more details, please refer to the letter that was
sent in response to the request for notification/prior authorization. If you disagree with this
decision, you or your healthcare provider may submit additional scientific evidence or
medical records for further review.
Id. at 277 (emphasis added). It is unclear what letter the EOB notes are referring to–the
administrative record (Dkt. # 49-1) and agreed supplemental record (Dkt. # 57) do not appear to
contain a letter that meets this description.
On October 3, 2018, Mercy Hospital submitted a fourth claim to UHC for $49,546.59. Id.
at 281-85. This claim, like the September 19, 2018 claim (Dkt. # 49-1, at 271), contains three
separate line items for OR services, with procedure codes that match the codes written on the
January 24, 2018 insurance verification note. Compare Dkt. # 49-1, at 282, with Dkt. # 57, at 8.
On October 5, 2018, UHC sent plaintiff an EOB statement notifying her of UHC’s benefits denial
of the $49,546.59 Mercy Hospital claim, stating in the notes, “[p]ayment for this service is denied.
Benefits are only available when you receive services from a provider in your plan’s network.” Dkt.
# 49-1, at 289. This is the first time UHC based the denial on the receipt of services from a provider
not in the plan’s network.

7
On October 19, 2018, and October 26, 2018, respectively, Mercy Hospital re-submitted the
hospital services claim for a fifth and sixth time to UHC for $49,546.59. Id. at 293-302. UHC sent
plaintiff an EOB statement on November 2, 2018, again notifying her that it was denying benefits
for the $49,546.59 Mercy Hospital claim. Id. at 304. The accompanying EOB notes state:

“[p]ayment for this service is denied. Benefits are only available when you receive services from
a provider in your plan’s network.” Id. Consequently, plaintiff received a “revised bill from Mercy
dated November 20, 2018, stating [p]laintiff owed $49,346.59 . . . . [And,] [i]n January 2019, Mercy
initiated collection efforts against [p]laintiff . . . through the collection agency Receivable Solutions,
Inc.” Dkt. # 61, at 6.
Finally, the administrative record shows that Mercy Hospital appealed the adverse benefit
determination again in April 2020, which UHC denied for untimeliness. Dkt. # 49-1, at 314.
Specifically, UHC’s denial of appeal letter, dated April 21, 2020, states, in pertinent part, “[y]ou
asked us to take another look at our initial decision. We have completed our review and confirmed

that the claim was processed correctly. As a result, we are unable to issue any further payment.”
Id. And, in the next paragraph, under the heading “Why was this decision made?” UHC states:
“[t]he health plan requires that reconsiderations are filed within 180 days from the date you received
your [EOB statement]. We received your reconsideration after the deadline.” Id. However, the
administrative record does not contain any letter or other documentation from Mercy Hospital
requesting the reconsideration that preceded UHC’s April 21, 2020 letter (Dkt. # 49-1, at 314).
Notwithstanding, the agreed supplemental record contains UHC’s date-stamped ORS history that
logged: that “provider sent recon[sideration] request”; who opened and who assigned the record; and

states “according to your contract, reconsideration requests/appeals must be submitted within the
8
timely filing limit. this reconsideration request/appeal was received beyond the timely filing limit.
this reconsideration request/appeal was received beyond the . . . deadline, and therefore, will not be
considered.” Dkt. # 57, at 10.
II.

Plan beneficiaries, like plaintiff, have the right to federal court review of benefit denials and
terminations under ERISA. “ERISA was enacted to promote the interests of employees and their
beneficiaries in employee benefit plans.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 113
(1989). Specifically, 29 U.S.C. § 1132(a)(1)(b) grants plaintiff the right “to recover benefits due to
[her] under the terms of the plan, to enforce [her] rights under the terms of the plan, or to clarify
[her] rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(b).
While the Court’s default standard of review is de novo, when a plan gives the plan

administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe
the terms of a plan, as here, a challenge under § 1132(a)(1)(B) is ordinarily reviewed under an
arbitrary and capricious standard. See Firestone, 489 U.S. at 115 (applying a deferential standard
of review when the plan administrator or fiduciary has discretionary authority to determine
eligibility for benefits or to construe the terms of a plan). Under the “pure” version of this standard,
a plan administrator’s or fiduciary’s decision will be upheld “so long as it is predicated on a
reasoned basis.” Adamson v. Unum Life Ins. Co. of Am., 455 F.3d 1209, 1212 (10th Cir. 2006).

By contrast, “[i]ndicia of arbitrary and capricious decisions include lack of substantial
evidence, mistake of law, bad faith, and conflict of interest by a fiduciary.” Caldwell v. Life Ins. Co.
of N. Am., 287 F.3d 1276, 1282 (10th Cir. 2002). “Substantial evidence is such evidence that a
reasonable mind might accept as adequate to support the conclusion reached by the [decision
9
maker]. Substantial evidence requires more than a scintilla but less than a preponderance.” Sandoval
v. Aetna Life & Cas. Inc. Co., 967 F.2d 377, 382 (10th Cir. 1992) (internal quotations omitted). A
plan administrator’s decision is afforded less deference where it “fails to gather or examine relevant
evidence.” Caldwell, 287 F.3d at 182. In other words, “fiduciaries cannot shut their eyes to readily

available information when the evidence in the record suggests that the information might confirm
the beneficiary’s theory of entitlement and when they have little or no evidence in the record to
refute that theory.” Gaither v. Aetna Life Ins. Co., 394 F.3d 792, 807 (10th Cir. 2004).
The Tenth Circuit has held that “in reviewing a plan administrator’s decision for abuse of
discretion, the federal courts are limited to the administrative record–the materials compiled by the
administrator in the course of making his decision.” Hall v. UNUM Life Ins. Co. of Am., 300 F.3d
1197, 1201 (10th Cir. 2002). “However, [the Supreme Court] left open the issue of what evidence

may be considered by a federal court in an action under § 1132(a)(1)(B) when de novo review is
required.” Id. And, the Tenth Circuit has found that reviewing a benefits denial de novo may be
appropriate “where there were procedural irregularities in the administrator’s consideration of the
benefits claim.” LaAsmar v. Phelps Dodge Corp. Life, Accidental Death & Dismem. and Dependent
Life Ins. Plan, 605 F.3d 789, 797 (10th Cir. 2010).
Finally, ERISA’s “interests are not served by federal court review of an incomplete
administrative record. . . . In [circumstances with] procedural irregularit[ies] and [a] resulting

incomplete record . . . the appropriate remedy is a remand[.]” Messick v. McKesson Corp., 640 F.
App’x 796, 799 (10th Cir. 2016); see also Rekstad v. U.S. Bankcorp, 451 F.3d 1114, 1121 (10th Cir.
2006) (concluding that a remand for further findings or explanations is the proper remedy where a
plan administrator’s decision was so one-sided that the court was unable to determine the
10
substantiality of the evidence supporting the benefits determination); Gaither, 394 F.3d at 806 n.5
(finding that merely affording a plan administrator’s decision less deference per Caldwell, 287 F.3d
at 1282, is inappropriate where a court is unable to determine the reasonableness of a benefits
determination due to the plan administrator’s failure to investigate).

The parties disagree over whether UHC’s benefits denial should be reviewed de novo or
under the arbitrary-and-capricious standard. Plaintiff argues that “[t]he proper standard of review
of [d]efendant’s decision is de novo because of [d]efendant’s blatant disregard for procedural
safeguards.” Dkt. # 61, at 7. Defendant responds that “[w]here, as here, an ERISA plan grants
discretionary authority to an insurer, the insurer is entitled to judgment in its favor unless the
[p]laintiff can demonstrate that its decision was an abuse of discretion.”5 Dkt. # 70, at 13. For the
reasons stated below, the Court finds that it lacks a complete administrative record to review. Thus,

the Court cannot determine the appropriate standard of review for UHC’s benefits denial, andUHC’s

5 The Court notes that defendant’s response to plaintiff’s opening brief (Dkt. # 70) is replete
with factual errors, miscitations, and mischaracterizations. See, e.g., Dkt. # 70, at 9-10
(incorrectly stating that plaintiff’s 2017 procedure was performed by Dr. Hughes and that
it was a breast reconstruction procedure), 10 n.25 (citing pages 272-76 of the record for the
proposition that plaintiff’s claim was denied because Mercy Hospital is a non-network
facility and UHC had not authorized the service; however, pages 272-76 only stand for the
proposition that UHC paid $0 for plaintiff’s Mercy Hospital claim), 15 (stating that as a
result of Mercy Hospital’s appeal, “claims for the surgeon, anesthesiologist, laboratory
services, and other Network providers were processed as covered expenses” and citing pages
275-80 of the record in support; however, pages 275-80 are the September 25, 2018 EOB
statement, and the surgical services claim included therein is for Freeman, not Mercy
Hospital, with a date of service of September 18, 2018. Moreover, plaintiff’s February 23,
2018 EOB statement (Dkt. # 49-1, at 245-48) clearly shows that UHC paid Dr. Hughes,
plaintiff’s surgeon, before Mercy Hospital even submitted its claim for hospital services on
February 26, 2018, Dkt. # 49-1, at 252-55, and before Mercy Hospital appealed UHC’s
denial on March 28, 2018, Dkt. # 57, at 6-7).
11
decision should be remanded for further findings and explanations consistent with the Court’s
findings below.

III.
The administrative record (Dkt. # 49-1) and agreed supplemental record (Dkt. # 57) indicate
numerous procedural irregularities and missing documents. Importantly, the Tenth Circuit has found
that in circumstances where a plan administrator fails to meet ERISA’s minimum claims procedure
standards, the Code of Federal Regulations (CFR) provides that “a claimant shall be deemed to have
exhausted the administrative remedies available under the plan . . . on the basis that the plan has
failed to provide a reasonable claims procedure that would yield a decision on the merits of a claim.”

LaAsmar, 605 F.3d at 798 (citing 29 C.F.R. § 2560.503-1(l)) (emphasis in original).
a. Procedural Irregularities
ERISA contemplates “an ongoing, good faith exchange of information between the
administrator and the claimant[.]” Gilbertson v. Allied Signal, Inc., 328 F.3d 625, 635 (10th Cir.
2003). Pursuant to ERISA’s mandate, the CFR “sets forth minimum requirements for employee

benefit plan procedures pertaining to claims for benefits by participants and beneficiaries.” 29 C.F.R.
§ 2560.503-1(a). These minimum requirements include an “[o]bligation to establish and maintain
reasonable claims procedures . . . governing the filing of benefit claims, notification of benefit
determinations, and appeal of adverse benefit determinations[.]” 29 C.F.R. § 2560.503-1(b).

12
i. Failure to Utilize Procedural Safeguards
An employee benefit plan’s “claims procedures . . . [must] contain administrative processes

and safeguards designed to ensure and verify that benefit claim determinations are made in
accordance with governing plan documents[.]” 29 C.F.R. § 2560.503-1(b)(5).
The administrative record shows procedural inconsistencies between UHC’s management
of plaintiff’s insurance verification for her 2017 mastectomy procedures at Freeman, and the
subsequent 2018 Mercy Hospital insurance verification for plaintiff’s breast reconstruction
procedures. Specifically, before plaintiff’s bilateral mastectomy, UHC sent plaintiff a confirmation
of coverage for the procedures. Dkt. # 49-1, at 177-78. In other words, UHC had a reasonable

procedural safeguard to ensure accurate verification of covered health services.
With respect to the 2018 Mercy Hospital procedures, the January 24, 2018 insurance
verification note (Dkt. # 57, at 8) provides powerful circumstantial evidence that Mercy Hospital
was informed by UHC that it was an in-network facility, and--critically--that no prior authorization
was required because of plaintiff’s previous breast cancer diagnosis. See Dkt. # 57, at 8. The record
shows that the January 24, 2018 insurance verification note is corroborated by: 1) plaintiff’s policy,
which states a deductible amount, out-of-pocket maximum, and co-insurance structure that exactly

matches the details written in the note, Dkt. # 49-1, at 27-29, 33-34, 37; 2) Mercy Hospital’s March
28, 2018 appeal letter, which references a “precert” call with UHC during which Mercy Hospital
was informed that no prior authorization was required, Dkt. # 57, at 6-7; and 3) Mercy Clinic’s
February 2018 (Dkt. # 49-1, at 242), and Mercy Hospital’s September 2018 (Dkt. # 49-1, at 270-74)
and October 2018 (Dkt. # 49-1, at 281-85, 293-302) claims, which contain the same procedure codes
as the ones written in the January 24, 2018 insurance verification note, Dkt. # 57, at 8. It is unclear
13
why UHC did not utilize a prior authorization mechanism, like the confirmation of coverage that
plaintiff received before her 2017 mastectomy (Dkt. # 49-1, at 177-78), which would have served
as a procedural safeguard against mistakes or miscommunications regarding Mercy Hospital’s out-
of-network status. The note indicates that UHC informed Mercy Hospital that no authorization was

required, Dkt. # 57, at 8, even though UHC has prior authorization procedures–e.g. sending plan
beneficiaries written confirmation of coverage for specific health care services–that could have
easily prevented this situation. But for the miscommunication among Dr. Hughes’s office, Mercy
Hospital, and UHC (that Mercy Hospital was in-network and no prior authorization was required
for plaintiff’s procedures), plaintiff could have easily elected to undergo the breast reconstruction
procedure at an in-network facility, such as Freeman. Had plaintiff been made aware that Mercy
Hospital was out-of-network (which should have been the case if UHC and Mercy Hospital had
utilized adequate procedural safeguards to ensure plaintiff was notified that Mercy Hospital was out-
of-network), she could have made an informed decision as to whether she would go forward with

her procedure at an out-of-network facility or request an in-network facility.
Nevertheless, the record indicates that there was some procedural defect, miscommunication,
or other error that the plan administrator reviewing claimant’s appeal should have investigated,
gathered evidence confirming or refuting, and explicitly addressed in its denial of appeal (Dkt. # 49-
1, at 265).

14
ii. Failure to Meet Minimum Standards for Manner and Content of Adverse
Benefit Determinations
Any adverse benefit determination “notification shall set forth, in a manner calculated to be
understood by the claimant–(i) [t]he specific reason or reasons for the adverse determination”; “(ii)
[r]eference to the specific plan provisions on which the determination is based”; and “(iii) [a]

description of any additional material or information necessary for the claimant to perfect the claim
and an explanation of why such material or information is necessary[.]” 29 C.F.R. § 2560.503-
1(g)(1)(i-iii); see also Caldwell, 287 F.3d at 1288 (finding that ERISA § 1133(1) requires a claims
administrator to “provide adequate notice to any participant whose claim has been denied, ‘setting
forth the specific reasons for such denial . . . .’”).
Here, the content and manner of UHC’s March 2018 (Dkt. # 49-1, at 256-59), September
2018 (Dkt. # 49-1, at 275-77), October 2018 (Dkt. # 49-1, at 286-89), and November 2018 (Dkt. #

49-1, at 303-04) notifications of adverse benefit determination fall far short of the “minimum
requirements” set forth in ERISA, the accompanying CFR rules, and Tenth Circuit precedent.
Specifically, UHC’s March 2018 EOB statement states, in pertinent part, "[b]ased on the
information provided, this service does not meet coverage requirements as defined in your plan.
Therefore, no benefits are payable for this expense." Dkt. # 49-1, at 258. The Court finds that this
notification of adverse benefit determination is impermissibly vague and non-specific. The plan’s
“coverage requirements” could refer to any portion of the 175-page plan that has any relevance to

eligible expenses--for example, the schedule of benefits (Dkt. # 49-1, at 25-44), the certificate of
coverage (Dkt. # 49-1, at 52-121), the section on covered health services (Dkt. # 49-1, at 52-71), the
section on exclusions and limitations (Dkt. # 49-1, at 72-82), the section on defined terms (Dkt. #
15
49-1, at 112-21), and so forth. Moreover, the CFR requires UHC to reference the specific provisions
of the plan that UHC relied on in making the adverse determination. 29 C.F.R. § 2560.503-
1(g)(1)(ii). Here, UHC merely states “as defined in your plan,” which provides inadequate guidance
to plaintiff as to which provision in the policy UHC is relying on to deny benefits. And, UHC is

required to state, in a manner calculated to be understood by claimant, what additional information
or material is necessary to perfect the claim. 29 C.F.R. § 2560.503-1(g)(1)(iii). Notwithstanding,
UHC’s March 2018 EOB notes state that “in order for [Mercy Hospital’s claim] to be considered
for coverage, [plaintiff] or [Mercy Hospital] must submit either scientific evidence, skilled care
information or medical records that demonstrate how this service meets [UHC’s coverage
requirements].” Id. This boiler-plate request for information does not provide any specific
indication to the claimant as to why the claim was denied, and the request for scientific evidence and
medical records is vague and potentially misleading. If UHC’s denial was because Mercy Hospital
is an out-of-network facility, then it is unclear why UHC requested scientific evidence, skilled care

information, or medical records, as opposed to explicitly requesting documentation as to whether
Mercy Hospital and/or plaintiff obtained prior authorization to use an out-of-network facility. And,
UHC failed to explain why the requested documentation is necessary, as the CFR requires, 29 C.F.R.
§ 2560.503-1(g)(iii), which could have served as a procedural safeguard against Mercy Hospital’s
misinterpretation of UHC’s adverse benefit determination. In sum, UHC’s vague reason for denying
benefits, that is, that the service does not meet coverage requirements; its failure to reference a
specific provision in the plan; and its boiler-plate request for additional information does not provide
adequate notice to plaintiff regarding the March 2018 adverse benefit determination because it does

16
not meet ERISA’s minimum procedural standards. See Caldwell, 287 F.3d at 1288; 29 C.F.R. §
2560.503-1(g)(1)(i-iii).

Next, UHC’s September 2018 EOB statement, notifying plaintiff of its denial of Mercy
Hospital’s claim states, in pertinent part, “[b]enefits for this service are denied. Based on a review
of the information provided, this service is not covered under your plan. For more details, please
refer to the letter that was sent in response to the request for notification/prior authorization.” Again,
the reason for denial is vague and non-specific. First, UHC does not set forth a specific reason why
the service is not covered–i.e., that Mercy Hospital is an out-of-network facility. Second, it is
unclear what provided information was reviewed in reaching the determination. Third, UHC does
not reference a specific provision in plaintiff’s plan forming the basis of the denial. Fourth, UHC
references a letter that was sent, which purportedly contains more details, but it is unclear what letter

UHC is referencing--there is no information about the date of the letter or to whom the letter was
sent. It is unclear whether the administrative record contains the referenced letter. The Court notes,
however, that the record does not appear to contain a letter that makes an unambiguous, explicit
request for notification or prior authorization for the February 14, 2018 procedure. In sum, like the
March 2018 EOB statement, UHC’s September 2018 EOB statement does not provide adequate
notice to plaintiff regarding an adverse benefit determination because it does not meet ERISA’s
minimum procedural standards; that is, stating with specificity the reason for denial, the specific
plan provision forming the basis of the denial, and a description of what information or material is

necessary to perfect the claim and why.
UHC’s October 2018 (Dkt. # 49-1, at 286-89) and November 2018 (Dkt. # 49-1, at 303-04)
EOB statements also fall short of ERISA’s procedural requirements. Specifically, the EOB notes
17
state “[p]ayment for this service is denied. Benefits are only available when you receive services
from a provider in your plan’s network.” Dkt. # 49-1, at 289, 304. While this explanation is more
specific than those provided in the March 2018 and September 2018 EOB statements and is the first
mention of an out-of-network provider, the purported reason is still ambiguous. For example,

plaintiff’s plan states “[n]etwork providers are independent practitioners. They are not our
employees[,]” Dkt. # 49-1, at 42, which implies that a provider is a person--such as a physician--not
a facility. Dr. Hughes, who performed plaintiff’s surgery, is an in-network provider, while the
facility, where the surgery was performed, is a non-network provider. Accordingly, ERISA requires
that UHC set forth the reason for denial in a manner calculated to be understood by plaintiff. Thus,
given the potential for confusion as to which health care services provider UHC is referring to, it is
unclear why UHC did not state with specificity that benefits are denied because the facility
providing services is an out-of-network facility and the claimant did not notify UHC or obtain prior
authorization. Moreover, UHC again failed to reference the specific provision in the plan that forms

the basis of the decision, and did not request additional material to confirm whether there was prior
authorization.
In sum, each EOB statement that UHC sent to plaintiff had procedural deficiencies impeding
the development of a complete record. ERISA’s purpose is to protect plan beneficiaries, such as
plaintiff, by mandating certain minimum procedural requirements for claims. These minimum
procedural requirements not only ensure that the plan administrator provides adequate notice to a

claimant of an adverse determination, but they also promote the development of a complete
administrative record. For example, if UHC had communicated to plaintiff or Mercy Hospital--with
specificity--that the adverse determination was due to Mercy Hospital’s out-of-network status, the
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claimant could have provided UHC with information substantiating notification or prior
authorization, such as the January 24, 2018 insurance verification note (Dkt. # 57, at 8).
Consequently, the plan administrator could have investigated and gathered evidence pertaining to
this communication between UHC and Mercy Hospital, thereby developing the administrative

record on a critical point of contention in this case. Moreover, a claimant is disadvantaged on appeal
when an adverse determination does not set forth a specific reason or specific plan provision,
particularly when, as here, the EOB notes provide little to no guidance on what the claimant should
raise or address on appeal. Thus, the Court finds that UHC’s inadequate adverse benefit
notifications contradict ERISA’s purpose, that is, to protect plan beneficiaries, and inhibited the
development of a complete administrative record.
iii. Failure to Meet Minimum Standards for Notification of Adverse Benefit
Determination on Review

For appeals of adverse benefit determinations, “[e]very employee benefit plan shall establish
and maintain a procedure by which a claimant shall have a reasonable opportunity to appeal an
adverse benefit determination . . . [and] there will be a full and fair review of the claim and the
adverse benefit determination.” 29 C.F.R. § 2560.503-1(h)(1). Full and fair review requires
“tak[ing] 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)(iv). Moreover, the
notification of an adverse benefit determination on review “shall set forth, in a manner calculated
to be understood by the claimant–(1) [t]he specific reason or reasons for the adverse determination”;

“(2) [r]eference to the specific plan provisions on which the benefit determination is based”; and “(3)
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[a] statement that the claimant is entitled to receive, 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.” 29 C.F.R. § 2560.503-1(j)(1-3).

It is apparent from Mercy Hospital’s appeal letter (Dkt. # 57, at 6-7) that the provider,
appealing on behalf of plaintiff, did not understand that the reason for denial was due to Mercy
Hospital’s out-of-network status. Namely, Mercy Hospital states in its appeal letter that “[t]he
insurance indicates the denial is for lack of medical necessity for inpatient.” Dkt. # 57, at 6. The
letter goes on to justify why the specific procedure performed on plaintiff is necessarily inpatient,
thus substantiating that Mercy Hospital misinterpreted UHC’s vague adverse benefit determination
notification. Further, Mercy Hospital’s appeal letter references a “precert” call; that UHC told
Mercy Hospital no prior authorization for the procedure was required; and it references a contractual

agreement between Mercy Hospital and UHC. Id. at 6-7. A full and fair review requires that UHC
take into account the information Mercy Hospital conveyed in its appeal letter. Based on the
administrative record, it does not appear that UHC undertook any investigation or gathered any
evidence to confirm or refute Mercy Hospital’s statement that they called for precertification and
UHC told it that no prior authorization was required. And, it is not apparent from the record that
UHC reviewed the referenced contractual agreement with Mercy Hospital during its consideration
of the appeal, and the administrative record does not appear to contain any such contract.

Moreover, the CFR requires that plan administrators write notifications of adverse benefit
determinations on review in a manner calculated to be understood by the claimant. Therefore, if
UHC denied the claim because of Mercy Hospital’s out-of-network status--and Mercy Hospital’s
appeal letter unequivocally conveys that it interpreted the denial as for lack of medical necessity--
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then UHC must necessarily clarify the reason for denial. In other words, because UHC failed to
clarify Mercy Hospital’s misinterpretation, UHC per se failed to write the notification of its denial
of appeal in a manner that is reasonably calculated to be understood by claimant. Specifically,
UHC’s reason for denying the appeal states “[b]ased on our review, we determined that we

processed this claim accurately . . . the claim was processed/paid at the contracted rate.” Dkt. # 49-
1, at 265. The Court finds that this explanation is vague and inadequate. Like the initial EOB
statements, the explanation does not set forth the specific reason for the denial, that is, Mercy
Hospital’s out-of-network status, and it does not set forth the specific plan provision forming the
basis of the determination. Further, the explanation does not address with specificity any of the
issues Mercy Hospital raised in its appeal letter (Dkt. # 57, at 6-7), such as the precertification call,
that Mercy Hospital was told that no preauthorization was required, and the referenced UHC-Mercy
Hospital contract. A full and fair review requires UHC to take this information into account, but the
administrative record contains no evidence that UHC considered this information, and UHC’s

notification of its denial of appeal (Dkt. # 49-1, at 256) does not explicitly address the information
provided by Mercy Hospital either. Therefore, the Court finds that UHC failed to meet ERISA’s
standards as to 1) full and fair review, and 2) the manner and content of adverse benefit notifications
on review. UHC’s failures deprived plaintiff of ERISA’s protections and resulted in an incomplete
record.
b. Missing Documents

The Tenth Circuit has found that federal court review of an incomplete record does not serve
ERISA’s purpose. Messick, 640 F. App’x at 799. Moreover, the Tenth Circuit has reversed and
remanded benefit determinations in circumstances where the plan administrator’s procedural defects,
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failure to investigate and make adequate findings, or one-sided consideration of evidence left a
reviewing court “unable to determine the substantiality of the evidence supporting” the plan
administrator’s decision. Rekstad, 451 F.3d at 1121; see also Gaither, 394 F.3d at 806 n.5. The
Court finds that the record in this case is incomplete because the administrative record (Dkt. # 49-1)

and supplemental administrative record (Dkt. # 57) indicate omissions, inconsistencies, and UHC’s
failure to investigate and make adequate findings.
i. Call Logs
Certain evidence corroborates Mercy Hospital’s January 24, 2018 insurance verification call
with UHC. Aside from the insurance verification note (Dkt. # 57, at 8), Mercy Hospital stated in

its March 28, 2018 appeal letter that it called UHC for precertification. Dkt. # 57, at 7. Thus, UHC
was on notice that Mercy Hospital allegedly contacted it for prior authorization for plaintiff’s
February 14, 2018 procedure. An adequate review and a complete record would contain evidence
that the plan administrator verified whether this call took place, and whether Mercy Hospital was
informed that it was in-network and that no prior authorization was required. As it stands, 1) the
insurance verification note (Dkt. # 57, at 8); 2) the Mercy Hospital appeal letter (Dkt. # 57, at 6-7);
3) plaintiff’s specific policy details–i.e., her deductible, out-of-pocket maximum, and co-insurance
structure--written on the insurance verification note (compare Dkt. # 49-1, at 27-29, 33, with Dkt.
# 57, at 8); and 4) the identical procedure codes on the January 24, 2018 insurance verification note

(Dkt. # 57, at 8), Mercy Clinic’s claim for Dr. Hughes’s services (Dkt. # 49-1, at 245-48), and Mercy
Hospital’s claims on September 19, 2018 (Dkt. # 49-1, at 271), October 3, 2018 (Dkt. # 49-1, at
282), and October 19, 2018 (Dkt. # 49-1, at 294) provide powerful circumstantial evidence that
Mercy Hospital verified plaintiff’s coverage and notified UHC of plaintiff’s procedure on January
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24, 2018, weeks before her surgery. Thus, UHC’s review, and the accompanying administrative
record, must include some form of investigation and evidence gathering--including call logs and any
accompanying notes, if such logs are kept--that either confirms or refutes the January 24, 2018
insurance verification call between Mercy Hospital and UHC.

ii. Mercy-UHC Contract
The existing record also indicates that Mercy Hospital has a contract with UHC.
Specifically, the March 28, 2018 appeal letter stated that Mercy Hospital’s “agreement with UHC
is that if there is a disagreement over the status [of a procedure], that UHC will contact [Mercy
Hospital].” Dkt. # 57, at 6. Moreover, UHC’s April 20, 2018 response letter denying Mercy

Hospital’s appeal stated that “[n]o further payment is due because the claim was processed/paid at
the contracted rate.” Dkt. # 49-1, at 265. Additionally, UHC’s ORS log regarding Mercy Hospital’s
April 2020 reconsideration request states that “[a]ccording to your contract, reconsideration
requests/appeals must be submitted within the timely filing limit.” Dkt. # 57, at 10. Taken together,
there are several references to a contract, and an adequate review and complete record would include
a copy of any relevant Mercy Hospital-UHC contracts; evidence that the plan administrator reviewed
such contracts; and evidence of a specific contractual provision forming the basis for UHC paying
$0 for Mercy Hospital’s billed amount.

iii. Online Routing System History
Based on Freeman’s 2017 appeal (Dkt. # 49-1, at 235-36) and Mercy Hospital’s 2020 appeal
(Dkt. # 57, at 10), UHC utilizes claim management and tracking software --the ORS. The record
and agreed supplemental record include ORS history for the 2017 and 2020 appeals; however, the
record does not contain the ORS history for Mercy Hospital’s March 2018 appeal. The 2017 and
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2020 ORS documents confirm that the ORS history could contain critical information, such as the
provider’s network status, date-stamped notes from UHC administrators reviewing the claim,
reasons for a particular course of action, and so forth. An adequate review and a complete record
would contain the entire ORS history relevant to plaintiff’s Mercy Hospital procedures, and, at

minimum, the entire ORS history of the March 28, 2018 appeal.
iv. Provider Remittance Advice
Documents in the administrative record confirm that UHC sends service providers PRA
statements. For example, when Freeman submitted claims for plaintiff’s 2017 procedures, UHC sent
Freeman PRA statements indicating the amount UHC paid, and notes as to contractual obligations

and why certain adjustments were made. See Dkt. # 49-1, at 205-14. Thus, it is unclear why UHC
did not include any PRA statements regarding the Mercy Hospital claims in the administrative
record. PRA statements could contain pertinent information concerning what UHC stated to Mercy
Hospital as to the adverse benefit determination, any contractual agreements, what information was
needed to perfect the claim, and so forth. UHC paid Mercy Clinic’s February 20, 2018 claim (Dkt.
# 49-1, at 240-43) for Dr. Hughes’s services, Dkt. # 49-1, at 247; thus, there should exist, at the very
least, a PRA statement for that payment. An adequate review and complete record would contain
evidence that the plan administrator reviewed the relevant PRA statements during the appeals
process as part of its investigation and evidence gathering.

24
v. Reimbursement Policy Guidelines
In its March 8, 2018 EOB statement (Dkt. # 49-1, at 256-58), which gave rise to Mercy

Hospital’s March 28, 2018 appeal letter (Dkt. # 57, at 6-7), UHC states that the “service does not
meet coverage requirements as defined in your plan.” Dkt. # 49-1, at 258. According to the plan’s
terms, “[e]ligible [e]xpenses are determined solely in accordance with [UHC’s] reimbursement
policy guidelines, as described in the Certificate [of Coverage].” Id. at 41. In the Certificate of
Coverage, the plan states that UHC “develop[s] [its] reimbursement policy guidelines, as [it]
determine[s], in accordance with one or more of the following methodologies:” 1) “[a]s indicated
in the most recent edition of the Current Procedural Terminology . . . and/or Centers for Medicare
and Medicaid Services”; 2) “[a]s reported by generally recognized professionals or publications”;
3) “[a]s used for Medicare”; and 4) “[a]s determined by medical staff and outside medical

consultants pursuant to other appropriate sources or determinations that we accept.” Id. at 49-50.
Further, “non-Network providers . . . may bill [beneficiaries] for . . . amounts that are denied because
one of [UHC’s] reimbursement policies does not reimburse (in whole or in part) for the service
billed.” Id. at 50. Notwithstanding, the Certificate of Coverage does not explicitly describe the
reimbursement policy guidelines that UHC relies on in making benefit determinations. In other
words, the plan does not put plaintiff on notice as to what reimbursement policy guidelines were
applied in making her adverse benefit determination. However, if the plan administrator relied on
specific reimbursement policy guidelines as to plaintiff’s February 14, 2018 procedures, then an

adequate review and complete record would include a copy of the reimbursement policy guidelines
document and reference to the specific provision(s) of the guidelines that the plan administrator
relied on.
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In sum, the Court finds that the administrative record is missing critical evidence, without
which the Court is unable to evaluate the substantiality of the evidence relied on by the plan
administrator in denying benefits for plaintiff’s Mercy Hospital claim. A complete record would
include: 1) evidence confirming or refuting the January 24, 2018 insurance verification call,

preferably with call logs; 2) any contractual agreements between Mercy Hospital Springfield and
UHC that were in effect between January 2018 and April 2020; 3) every ORS record related to
plaintiff’s February 14, 2018 procedure; 4) every PRA statement that UHC sent to Mercy Hospital
and/or Clinic related to plaintiff’s February 14, 2018 procedure; 5) the full text of the
reimbursement policy guidelines UHC relied on for each adverse benefit determination as to
plaintiff’s February 14, 2018 procedure, including, for the March 2018, September 2018, October
2018, November 2018, and April 2020 adverse determinations.

IV.
The Court finds that this case should be remanded to UHC. The Tenth Circuit has given
district courts the following guidance in deciding whether to remand a case to the plan administrator
for a review of plaintiff’s case: “if the plan administrator ‘fail[ed] to make adequate findings or to
explain adequately the grounds of [its] decision,’ the proper remedy ‘is to remand the case to the
administrator for further findings or explanation[.]’” DeGrado v. Jefferson Pilot Fin. Ins. Co., 451
F.3d 1161, 1175-76 (10th Cir. 2006) (alterations in original) (citations omitted). Here, as discussed

in Part III, supra, UHC failed to adequately explain the grounds for its decision and failed to make
adequate findings to substantiate its determination. Thus, the proper remedy is to remand plaintiff’s
case to UHC for further findings and explanations in line with this opinion and order and ERISA’s
explicit minimum standards, See, e.g., 29 U.S.C. § 1133; 29 C.F.R. § 2560.503-1(g-h). UHC is
26
advised that, even if a deferential standard applies, an adverse benefits determination that does not
account for and adequately refute the powerful circumstantial evidence with respect to the January
24, 2018 insurance verification note would be arbitrary and capricious. UHC is further advised that
where the plan administrator fails to meet minimum ERISA standards for claims procedures,

plaintiff’s administrative remedies shall be deemed to have been exhausted, e.g., with respect to
timeliness of appeals, Dkt. # 49-1, at 314.
It is unclear where the fault lies as to the apparent miscommunication between Mercy
Hospital and UHC, but it is abundantly clear that the miscommunication did not involve plaintiff
Edith Evans. Notwithstanding, the impact of this miscommunication on plaintiff has been
significant. First, plaintiff was denied the opportunity to make an informed choice as to whether she
wanted to go forward with her breast reconstruction surgery at an out-of-network facility, or elect

to have her procedure at an in-network facility. Second, rather than clarify its agreement with UHC
and demand payment from UHC,6 Mercy Hospital has been attempting to collect payment from
plaintiff, for approximately $50,000 in hospital bills, through a debt collection agency, Dkt. # 61,
at 6. However, from the current record, it appears that the benefits denial (and resulting unpaid
Mercy Hospital bill) was due to an apparent miscommunication--that did not involve plaintiff--
between Mercy Hospital and UHC.

6 The Court is perplexed as to why UHC paid nothing at all on the Mercy Hospital claim,
unless there is a UHC-Mercy Hospital contract that specifically provides that no payment
is due in such circumstances.
27
V.

Finally, plaintiff moves, pursuant to Fed. R. Civ. P. 12, to dismiss, strike, or for a more
definite statement as to UHC’s counterclaim (Dkt. # 37, at 9) “to recover its reasonable and
necessary attorneys’ fees” under 29 U.S.C. § 1132(g). Dkt. # 40, at 1-2. Section 1132(g) states, in
pertinent part, “the court in its discretion may allow a reasonable attorney’s fee and costs of action
to either party.” 29 U.S.C. § 1132(g)(1).. However, The Supreme Court has held that “a fees
claimant must show some degree of success on the merits before a court may award attorney’s fees
under § 1132(g)(1).” Hardt v. Reliance Standard Life Ins. Co., 560 U.S. 242, 255 (2010). Given
that the Court is remanding plaintiffs claims to UHC for further findings and explanations
consistent with this opinion and order, the Court finds that defendant has not met its burden to show
some success on the merits of plaintiff's ERISA claim. See id. Therefore, any award of fees at this
time is premature, and plaintiffs motion to dismiss, strike, or clarify defendant’s counterclaim (Dkt.
# 40) is moot.

IT IS THEREFORE ORDERED that defendant UHC’s decision to deny plaintiff benefits
for Mercy Hospital’s claims for hospital services is remanded for further findings or explanations
consistent with this opinion and order. A separate judgment closing this case is entered herewith.

IT IS FURTHER ORDERED that plaintiff's motion to dismiss, strike, or clarify
defendant’s counterclaim (Dkt. # 40) is moot.

DATED this 2nd day of February, 2022.
□□□ SD
Chain bab
CLAIRE V.EAGAN \—
UNITED STATES DISTRICT JUDGE

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10386820. Public record. Not legal advice.