Case Background

Facts of Class Rep                              CalPERS and Anthem’s Standardized Representations

Definition of Allowable Amount              Fairhealth.org

Case Background

The legal issues, including about whether the placement and language of the third subpart of the “Allowable Amount” definition in the EOC allows CalPERS and/or Anthem unfettered discretion to calculate the “Allowable Amount” and the reimbursement at greatly reduced rates, are similar or identical across the class.

Each class member was enrolled or covered under CalPERS or Anthem PPO insurance, such as PERSCare, PERSChoice, PERSSelect or similar PPO coverage.

Each class member enrolled in the PPO coverage using the same or similar standardized forms.

Each class member was bound by the same or similar EOC.

Each class member submitted claims for out-of-network medical expenses to CalPERS and Anthem and received reimbursement at an unreasonable rate that was below industry standards.

CalPERS and/or Anthem breached the contract in the same or similar way, by failing to provide proper reimbursement.

The class members suffered under-reimbursement based on CalPERS’ and/or Anthem’s application of same or similar policy, practice, paradigm, standards, formulas, or theories, or use of the same or similar source of information, data, or computer program.

CalPERS and/or Anthem utilized the same or similar policy, practice paradigm, standards, formulas, theories, source of information, data, or computer program when it calculated the Allowable Amounts for the CalPERS Anthem PPO coverage for “out-of-network” medical expenses at an improperly reduced rate.

CalPERS and Anthem caused the class members injuries in the same or similar way, by using inappropriately low Allowable Amounts to reduce reimbursement for out-of-network medical services.

The class members are similarly situated as they each suffer similar or common injuries of reduced reimbursement for “out-of-network” medical expenses that were presented and paid by Anthem and/or CalPERS, albeit at a reduced rate.

CalPERS and/or Anthem breached their contractual duties to Plaintiffs in the same or similar manner.

CalPERS and/or Anthem were unjustly enriched, et al in the same or similar fashion.

The representations in Anthem’s and CalPERS’ documents and non-negotiable form contracts were standardized and applied uniformly over specific long periods of time.

CalPERS owed and still owes the same or similar fiduciary duties to all class members.

CalPERS’ breaches its fiduciary duties, including the duty to inform, duty of good faith and fair dealing, the duty to account, the duty of loyalty, duty to not take advantage, and other fiduciary duties are in the same or similar manner for all class members. For example, CalPERS breaches it duty of loyalty to all class members in the same or similar manner when it offers or pays compensation for Anthem performance as it relates to reducing the reimbursement below reasonable levels.

The presumption of Plaintiffs’ reliance on Anthem, CalPERS, and CalPERS’ representations were the same or similar for all class members.

CalPERS’ breach of fiduciary duties proximately and directly caused Plaintiffs’ harm in the same or similar manner, including based on the presumption of reliance.

Plaintiffs’ claims for damages are the same or similar in cause and arise from the same or similar proximate cause, acts and omissions by CalPERS and/or Anthem.

Plaintiffs’ claims for increased reimbursement, are the same or similar for all class members.

Plaintiffs’ claims for interest from the date of under-reimbursement, and other relief to place them back in the position that they would have been is the same or similar for all class members.

Plaintiffs’ claims for attorney fees and other relief is the same or similar for all class members.

CalPERS’ defenses, including on the EOC, are the same or similar across the class.

Anthem’s defenses, including that it offered appropriate reimbursement, are the same or similar across the class.