Zack v. Mclaren Health Advantage, Inc.

TERRENCE G. BERG, UNITED STATES DISTRICT JUDGE

I. Introduction

Judith Zack required surgery by a specialist to repair a serious and recurring hiatal hernia. The specialist surgeon she needed did not participate in her husband's, Dr. Paul Zack's, health insurance plan, which was offered by McLaren Heath Advantage, Inc. The plan paid full benefits for "in-plan" doctors but only 60% of a "reasonable and customary amount" for "out-of-plan" doctors. The plan itself *653does not say what "reasonable and customary amount" means or how it would be calculated. When the Zacks submitted their bill for…