1.  The Choice Plus Plan’s Coordination of Benefits with Medicare   19.    After enrolling in Medicare on August 1, 2010, Plaintiff purportedly should have  been transferred from the Choice Plus Plan to the Indemnity Plan.  As of the filing of this  complaint, Plaintiff has not yet been transferred to that Plan.     2.  The Indemnity Plan’s Coordination of Benefits with Medicare   20.    Under the terms of both Defendant Plans, Plaintiff’s coverage is secondary to her  benefits under Medicare.  See Summary Plan Description United HealthCare Choice Plus Copay  Plan for AllianceBernstein L.P., Jan. 1, 2009 at 62-63 (“Choice Plus Plan SPD”);  AllianceBernstein L.P. United HealthCare Indemnity, Jan. 1, 2009 at 40 (“Indemnity Plan SPD”).     21.    Medicare is required to use the Resource-Based Relative Value Scale (“RBRVS”)  to determine a medical provider’s payment amount for covered services.  The RBRVS assigns  medical procedures a relative value that is then adjusted according to geographic region and  multiplied by a fixed conversion factor, which changes annually.  The RBRVS’s underlying data  is published in the Federal Register.  Medical procedures are identified by Current Procedural  Terminology (“CPT”) codes.     23.    The Choice Plus Plan SPD provides that if a participant in the Choice Plus Plan is  enrolled in Medicare on a primary basis, Medicare pays benefits as the primary payer and the  Choice Plus Plan will pay as secondary payer.  Id. at 62-63.   24.    When the Choice Plus Plan “is secondary, it may reduce its benefits by the total  amount of benefits paid or provided by all [primary plans].”  Id. at 62.     25.    As each claim is submitted, United Insurance, as the Claims Administrator of the  Choice Plus Plan, will “(1) Determine [the Plan’s] obligation to pay or provide benefits under its  contract; (2) Determine the difference between the benefit payments that [the Choice Plus Plan]  would have paid had it been the Primary Coverage Plan and the benefit payments paid or provided  by [the primary plan].”  Id.     26.    If the primary plan paid less than is called for under the Choice Plus Plan, the  Choice Plus Plan will pay the difference.  Id.   27.    With regards to Medicare, the Choice Plus Plan states that it “reduces its benefits”  for plan participants who are eligible for Medicare when Medicare would be the Primary Plan.  Id.   29.    In a letter from AllianceBernstein to Plaintiff dated November 30, 2010,  AllianceBernstein explained:  [I]f a provider “opts” out of Medicare and the participant is Medicare-eligible, . . .  [United Insurance] will still pay the claim as if the provider accepted Medicare,  even if nothing is actually paid by Medicare.  To do this, [United Insurance] will  estimate what Medicare would have paid, as if a Medicare participating provider  was used, and then pay the appropriate amount.  Letter from Brian W. Fagan to Marianne Gates (Nov. 30, 2010) (emphasis added).   3.  Plaintiff’s Benefit Claims   30.    However, the Choice Plus Plan SPD clearly states that United Insurance, as the  Claims Administrator of the Choice Plus Plan, does not have discretion to estimate Medicare  payments.  Rather, as stated above, “Medicare benefits are determined as if the full amount that  would have been payable under Medicare was actually paid under Medicare.”  Choice Plus Plan  SPD at 62 (emphasis added).  As shown above, Medicare payment amounts are easily determined,  belying any need to estimate the payments.   31.    The Indemnity Plan coordinates benefits with Medicare in a similar manner as the  Choice Plus Plan.   33.    Once an employee becomes eligible for Medicare, the Indemnity Plan pays benefits  under the Plan as if the participant were covered under Medicare, whether the participant has  enrolled in Medicare or not.  Id.   34.    If a participant “receives services from a provider who has elected to opt-out of  Medicare[,] Medicare benefits are determined as if the services were covered under Medicare  Parts A and B and the provider had agreed to limit charges to the amount of charges allowed under  Medicare rules.” Id. at 41.   35.    As discussed below, Plaintiff alleges that United improperly estimates Medicare  benefits for all United Plans for which Medicare may be a primary payer.  Indeed, United’s  estimates greatly exceed the amounts that Medicare actually pays and result in United under- reimbursing United Plan participants and beneficiaries for covered services.   36.    Plaintiff received medical care from various physicians who charged varying  amounts for her visits.  Initially, Plaintiff’s claims were processed by United Insurance with the  Choice Plus Plan as the primary payer.  After Plaintiff became covered by Medicare, United  Insurance began processing Plaintiff’s claims with the Choice Plus Plan as secondary to Medicare.   37.    Some of Plaintiff’s medical providers have opted out of Medicare.  Thus, Plaintiff  is responsible for the amount that Medicare would have paid had Plaintiff’s providers participated  in Medicare.    38.    On numerous occasions, United Insurance improperly determined the amount that  Medicare would have paid had Plaintiff’s claim been covered by Medicare.     40.    On August 6, 2010, Plaintiff was seen by a medical professional and a claim was  submitted to United Insurance in the amount of $2,000.  The EOB dated August 30, 2010, reflects  that United Insurance determined that Medicare would pay $1,600.  However, the CMS fee  schedule database indicates that Medicare would have paid $191.61, which is less than an eighth  of the amount United Insurance had determined.   41.    On August 11, 2010, Plaintiff was seen by a medical professional and a claim was  submitted to United Insurance in the amount of $3,000.  An EOB dated September 27, 2010, states  that Medicare would have paid $2,400.  The EOB notes:  Medicare pays benefits before your group health plan.  Since the patient did not  enroll for Medicare part A and/or B we processed this claim after estimating how  much Medicare parts A and/or B would have covered.  The patient is responsible  for the difference between the billed charge and the amount paid by this Plan.  (Emphasis added).   42.    However, the CMS fee schedule database indicates that Medicare would have paid  a total of $508.88—only a fraction of what United Insurance determined Medicare would pay.   43.    On August 26, 2010, Plaintiff was seen by a medical professional and a claim was  submitted to United Insurance in the amount of $300.  The EOB dated September 27, 2010,  reflects that Medicare would have paid $240.  The CMS database indicates that Medicare actually  would have paid $55.23, less than a quarter of the amount United Insurance determined it would  pay.   45.    Once again, United Insurance vastly overestimated the amount Medicare would  have paid had Plaintiff’s provider been covered by Medicare.  The CMS database indicates that  Medicare would have paid $114.26—an amount that is nowhere near the amount that United  Insurance determined.   46.    On February 1, 2011, Plaintiff was seen by a medical professional and a claim was  submitted to United Insurance in the amount of $300.  The EOB dated March 24, 2011, states that  Medicare would have paid $240.  United Insurance did not cover any amount for this procedure.   The CMS database indicates that Medicare actually would have paid $55.23.   47.    On February 24, 2011, Plaintiff was seen by a medical professional and a claim  was submitted to United Insurance in the amount of $600.  The EOB dated April 20, 2011, states  that Medicare would have paid $480.  United Insurance did not cover any amount for this  procedure, and the CMS database indicates that Medicare actually would have paid $45.54, less  than a tenth of the amount United Insurance determined it would pay.   49.    United contracts with certain medical providers to provide covered services to the  United Plans’ participants and beneficiaries.  Accordingly, on information and belief, many of the  United Plans differentiate between services provided by such in-network providers from those  with whom United has not contracted—so-called out-of-network (“ONET”) providers.  Because  United has not negotiated fees with ONET providers, a United Plan might provide for  reimbursement of less than such providers’ service charges, leaving the participants and  beneficiaries liable for any difference.   50.    The Choice Plus Plan SPD defines Non-Network Benefits as “Benefits for Covered  Health Services that are provided by a non-Network Physician, non-Network facility, or other  non-Network provider.”  Choice Plus Plan SPD at 84.  The SPD does not describe how payments  for Non-Network Benefits are calculated.   51.    On July 19, 2010, Plaintiff was seen by a medical professional and claims were  submitted to United Insurance in the amounts of $150 and $75.  The EOB dated October 29, 2010,  limited the amounts allowed for these claims to $10 and $15 respectively.  The EOB also notes:  Your Plan covers reasonable charges for covered health services.  The reasonable  charge is based on amounts charged by other physicians or health care  professionals in the area for similar services or supplies.  Benefits are not available  for that portion of the charge that exceeds the reasonable charge determined for this  service.   52.    On July 29, 2010, Plaintiff was seen by a medical professional and a claim was  submitted to United Insurance in the amount of $300.  The EOB dated October 29, 2010, limited  the amount allowed for this claim to $180.  The EOB contains the same notation set forth in the  paragraph above.   54.    The Ingenix databases have been the subject of several lawsuits.  They have also  been the subject of a settlement agreement between the New York State Attorney General (the  “NYAG”) and UnitedHealth Group Inc. entered into on January 13, 2009, under Investigation No.  2008-I6I (the “Settlement”).   55.    Among other things, the NYAG’s investigation determined that Ingenix skewed the  databases so that reasonable and customary charges would be undervalued resulting in lower  reimbursements to United Plan participants and beneficiaries.  The investigation also found that  UnitedHealth Group Inc.’s ownership of the databases as well as its subsidiary insurance  companies’ use of the databases was a conflict of interest.   56.    The Settlement thus provides for the establishment of a database by FAIR Health,  Inc., a nonprofit group selected by the NYAG, to replace the Ingenix database.  This process is  being funded, at least in part, by a $50 million UnitedHealth Group Inc. contribution.   58.    The Settlement required UnitedHealth Group Inc. to post certain information on its  website.  Among other things, that portion of the website states:  If your health care plan requires payment using the term “reasonable and  customary” or similar language mentioned above with respect to medical and  surgical procedures performed and billed by health care professionals or health care  provider group practices, affiliates of UnitedHealth Group most commonly refer to  a schedule of charges created by Ingenix, Inc., a wholly owned subsidiary of  UnitedHealth Group when determining the maximum amount they will pay for  such benefits.  Ingenix publishes two databases called the Prevailing Healthcare  Charges System database (“PHCS Database”) and the Medical Data Research  database (“MDR Database”). The information in these databases is updated and  published by Ingenix at scheduled times each year.  UnitedHealth Group affiliates  which administer health care plans based on the term “reasonable and customary”  or similar standards use the medical or surgical modules of one of these databases  for reimbursement of professional fees for medical and surgical services.  Important Notice on Payment of Out-of-Network Benefits, http://www.uhc.com/legal/  payment_of_out_of_network_benefits/relatedinformation/dd1c6963c5190210VgnVCM20000030 10b10a____.htm (last visited May 18, 2011).   59.    However, in so doing, UnitedHealth Group Inc. and its subsidiaries have not, upon  information and belief, done anything to correct the data in the Ingenix databases that the NYAG  investigation found flawed.  Therefore, UnitedHealth Group Inc. and subsidiaries/affiliates  continue to reimburse ONET services at less than the actual reasonable and customary rate  required.   C.  United Insurance Failed to Comply with ERISA’s Claims Procedure Requirements   89.    Numerosity.  The members of each class are so numerous that joinder of all  members is impracticable.  Upon information and belief, each class consists of thousands of health  care subscribers whose benefits under the United Plans were underpaid because United Insurance  overstates Medicare payments and improperly calculates ONET reimbursement rates, and who did  not receive a full and fair review of their claims.  The precise number of members in each class is  within Defendants’ custody and control.  Based on reasonable estimates, the numerosity  requirement of Rule 23 is easily satisfied for each class.  Common questions of law and fact exist  as to all class members and predominate over any questions affecting solely individual members  of each class, including the class action claims and issues described herein.   90.    Commonality.  The following common class claims and issues arise for Plaintiff  and the Class:  (a)  whether Defendants violated ERISA;   (b)  whether Defendants’ alleged ERISA violations, if proved, justify injunctive  relief;  (c)  whether Defendants’ coordination of benefits procedures complied with  A.  United Improperly Determines the Amount Medicare Pays on Benefits Claims  