subsidiary of Health Net of the Northeast, Inc. (HN-NE). Health Net, Inc. (HNI) is the corporate parent not only of HN-NJ and HN-NE but also of other subsidiary insurance companies that provide medical benefits to participants in benefit plans established under the Employee Retirement Income Security Act
(ERISA), 29 U.S.C. § 1001 et formulation and administrative
services are shared among the
Net companies, a subsidiary is responsible for deciding in accordance with these policies and for paying claims
to participants subsidiaries do
from the not hold or
subsidiary’s assets. manage the assets of
HNI and its their customer
beneficiary HNI or any
from the subsidiary’s own of the subsidiaries obtains
funds. Similarly, when legal advice, counsel is
paid from HNI’s or the subsidiary’s funds. of the subsidiaries is a plan administrator the benefit plans.
Neither HNI nor any or trustee for any of
The plaintiffs are beneficiaries of two different employee benefit plans that purchased point-of-service policies from HN- NJ. Under the plaintiffs’ policies, health care providers are classified as in-network or out-of-network. When beneficiaries obtain care from out-of-network providers, they must pay a higher share of the cost than they would had they obtained care from in-network providers. In determining what percentage of an out-of-network charge HN-NJ will pay, HN-NJ will look to the Usual, Customary, and Reasonable (UCR) charge for the
In defining UCR charges, Health Net
companies rely on data contained in certain national databases.