United States District Court, D. Arizona
NEIL V. WAKE, District Judge.
Before the Court is United Healthcare Insurance Company's Motion for Summary Judgment (Doc. 36).
I. LEGAL STANDARD
Summary judgment is proper if the evidence shows there is no genuine issue as to any material fact and the moving party is entitled to judgment as a matter of law. Fed.R.Civ.P. 56(a). The moving party must produce evidence and show there is no genuine issue of material fact. Nissan Fire & Marine Ins. Co., Ltd. v. Fritz Cos., Inc., 210 F.3d 1099, 1102 (9th Cir. 2000). To defeat a motion for summary judgment, the nonmoving party must show that there are genuine issues of material fact. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 250 (1986). On summary judgment, the nonmoving party's evidence is presumed true, and all inferences from the evidence are drawn in the light most favorable to the nonmoving party. Eisenberg v. Ins. Co. of North America, 815 F.2d 1285, 1289 (9th Cir. 1987); Baldwin v. Trailer Inns, Inc., 266 F.3d 1104, 1117 (9th Cir. 2001).
But the evidence presented by the parties must be admissible. LRCiv 56.1(a), (b); see Fed.R.Civ.P. 56(c). Allegations in an unverified complaint are not admissible evidence. Conclusory and speculative testimony in affidavits and moving papers is insufficient to raise genuine issues of fact and to defeat summary judgment. Thornhill Publ'g Co., Inc. v. GTE Corp., 594 F.2d 730, 738 (9th Cir. 1979). "If a party fails to properly support an assertion of fact or fails to properly address another party's assertion of fact as required by Rule 56(c), the court may... consider the fact undisputed for purposes of the motion." Fed. R. Civ. 56(e)(2).
II. UNDISPUTED MATERIAL FACTS
Defendant United Healthcare Insurance Company ("United") is the insurer and administrator of the Renaud, Cook, Drury, Mesaros, PA Welfare Benefit Plan ("Plan"), which is an employee-sponsored benefit and welfare plan. The Beneficiary, who is identified in the Complaint as "Jane Doe, " is eligible to receive benefits under the Plan as an "enrolled dependent." Plaintiff Aviation West Charters, Inc. is not a member of United's network of contracted health care providers.
In January 2013, the Beneficiary went to Kauai for a vacation. On January 16, 2013, the Beneficiary requested approval of air transport. On January 16, 2013, Plaintiff transported the Beneficiary and her family members from their hotel in Kauai to Scottsdale Healthcare Osborn in Arizona via ground and private air transportation. Plaintiff submitted post-service claims to United seeking payment of $682, 510.00 for the transportation services it provided.
On January 19, 2013, United sent the Beneficiary a letter, with a copy to Plaintiff, stating that, based on the information submitted to United, the transportation services were not eligible expenses under the Plan. On July 12 and 18, 2013, United made payments to Plaintiff in the amounts of $374, 328.81 and $187, 413.11, respectively, related to the transportation services. In December 2013, United issued five separate Provider Explanation of Benefits statements to Plaintiff, informing Plaintiff that it was recouping the amounts paid for the transportation services by reducing the amount of funds that were otherwise payable to Plaintiff for other claims it had submitted to United.
The Plan includes the following provisions:
You may not assign your Benefits under the Policy to a non-Network provider without our consent. When an assignment is not obtained, we will send the reimbursement directly to you (the Subscriber) for you to reimburse them upon receipt of their bill. We may, however, in our discretion, pay a non-Network provider directly for services rendered to you. In the case of any such assignment of Benefits or payment to a non-Network provider, we reserve the right to offset Benefits to be paid to the provider by any amounts that the Provider owes us.
When you assign your Benefits under the Policy to a non-Network provider with our consent, and the non-Network provider submits a claim for payment, you and the non-Network provider represent and warrant the following:
The Covered Health Services were actually provided.
The Covered Health Services were medically ...