Case 2:22-cv-00659-TLN-AC Document 1 Filed 04/13/22 Page 1 of 5
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`Robert F. Keehn, Esq. (115848)
`rkeehn@rfk-law.com
`Law Office of Robert F. Keehn
`400 Corporate Pointe, Suite 300
`Culver City, CA 90230
`(310) 551-6525 telephone
`(310) 284-2654 facsimile
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`Attorney for Plaintiff
`Tracy Burningham
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`TRACY BURNINGHAM,
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`Plaintiff,
`vs.
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`THE WINE GROUP, INC. HEALTH
`BENEFIT PLAN,
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`Defendant.
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`UNITED STATES DISTRICT COURT
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`EASTERN DISTRICT OF CALIFORNIA
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`Case No.
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`COMPLAINT FOR DECLARATORY
`RELIEF, PLAN BENEFITS AND
`ENFORCEMENT OF RIGHTS
`UNDER EMPLOYEE RETIREMENT
`INCOME SECURITY ACT of 1974
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`[29 U.S.C. § 1132(a)(1)(B)]
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`Plaintiff TRACY BURNINGHAM hereby complains against defendant THE
`WINE GROUP, INC. HEALTH BENEFIT PLAN as follows:
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`JURISDICTION
`This action involves a dispute concerning benefits provided under an
`1.
`employee welfare benefit plan subject to ERISA, 29 U.S.C. § 1001 et seq.
`Accordingly, this Court has jurisdiction of this matter pursuant to 28 U.S.C.
`§ 1331 and pursuant to ERISA, 29 U.S.C. § 1132(e)(1). Venue in this judicial
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`1 Complaint
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`Case 2:22-cv-00659-TLN-AC Document 1 Filed 04/13/22 Page 2 of 5
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`district is proper under 28 U.S.C. § 1391(b)(1), in that the defendant ERISA plan
`resides here. Additionally, venue in this judicial district is proper under ERISA, 29
`U.S.C. § 1132(e)(2), in that the defendant ERISA plan is administered here, and
`because said defendant may be found here.
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`PRELIMINARY ALLEGATIONS
`Plaintiff TRACY BURNINGHAM (hereinafter “Burningham” or
`2.
`“plaintiff”) is an individual. Plaintiff is a resident of the County of Sonoma,
`California.
`Defendant THE WINE GROUP, INC. HEALTH BENEFIT PLAN
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`3.
`(hereinafter “the Wine Group Health Plan” or “defendant”) was at all relevant
`times, and now is, an “employee welfare benefit plan” within the meaning of the
`Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C.
`§ 1002(1).
`The Wine Group, Inc., based in Ripon, California, was at all relevant
`4.
`times, and now is, the designated “administrator” for the Wine Group Health Plan
`within the meaning of ERISA, 29 U.S.C. § 1002(16)(A)(i).
`5.
`At all relevant times, Burningham was a “participant” in and/or
`“beneficiary” of the Wine Group Health Plan within the meaning of ERISA, 29
`U.S.C. § 1002(7) and 29 U.S.C. § 1002(8), respectively.
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`FIRST CLAIM FOR RELIEF
`(Declaratory Relief under 29 U.S.C. § 1132(a)(1)(B))
`Plaintiff incorporates herein by this reference as though fully set forth
`6.
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`the allegations of Paragraphs 1 through 5, above.
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`7.
`The Wine Group Health Plan expressly provides benefits for
`substance abuse disorders and chemical dependency.
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`2 Complaint
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`Case 2:22-cv-00659-TLN-AC Document 1 Filed 04/13/22 Page 3 of 5
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`At all relevant times prior to October 2018, Burningham had a
`8.
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`history of alcohol addiction.
`9.
`From October 14, 2018 through November 3, 2018, Burningham was
`treated for alcohol addiction on an in-patient basis at Duffy’s Napa Valley Rehab
`(“Duffy’s”) in Napa Valley, California. Said admission and treatment was
`medically necessary for a variety of reasons, including the fact that plaintiff had to
`be treated with detox medications for some six days before she could even begin
`participation in a treatment program.
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`10. The cost of Burningham’s treatment at Duffy’s was approximately
`$38,000, a substantial portion of which plaintiff was forced to pay out-of-pocket.
`However, her ensuing claim for reimbursement to the Wine Group Health Plan’s
`claim fiduciary and agent, UMR, Inc., was denied for the ostensible reason that
`plaintiff’s admission to and treatment at Duffy’s had not in fact been medically
`necessary.
`11. Burningham submitted the mandatory administrative appeal to UMR,
`Inc. However, plaintiff’s appeal was rejected by UMR, Inc. on September 17,
`2019, again for the ostensible reason that plaintiff’s admission to and treatment at
`Duffy’s had not been medically necessary. Burningham therefore has satisfied any
`requirement for the exhaustion of administrative remedies.
`12. On four different occasions subsequent to her admission to and
`treatment at Duffy’s, Burningham was admitted on an in-patient basis to other
`rehabilitation treatment facilities in Northern California for the treatment of
`alcohol addiction. Each of those four admissions and treatment regimens was paid
`for by the Wine Group Health Plan and was either expressly or impliedly
`determined to be medically necessary. There was no meaningful distinction
`between plaintiff’s treatment at Duffy’s in October and November 2018 and the
`treatment she subsequently received at the other facilities.
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`3 Complaint
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`Case 2:22-cv-00659-TLN-AC Document 1 Filed 04/13/22 Page 4 of 5
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`13. A controversy has arisen and now exists between Burningham and
`defendant regarding plaintiff’s entitlement to benefits under the Wine Group
`Health Plan for her treatment at Duffy’s in October and November 2018. Plaintiff
`contends that her treatment was in fact medically necessary, and that the cost of
`said treatment should be reimbursed by defendant. The Wine Group Health Plan
`apparently contends that its claim fiduciary’s determination regarding lack of
`medical necessity was proper. A judicial declaration of the parties’ respective
`rights, obligations and liabilities therefore is necessary and appropriate at this time.
`14. As a result of the dispute and disagreement explained above, it has
`become necessary for Burningham to retain an attorney to enforce her rights under
`ERISA. Plaintiff therefore is entitled to an award of reasonable attorney fees and
`costs under ERISA, 29 U.S.C. § 1132(g)(1).
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`SECOND CLAIM FOR RELIEF
`(Plan Benefits and Enforcement of Rights under 29 U.S.C. § 1132(a)(1)(B))
`15. Plaintiff incorporates herein by this reference as though fully set forth
`the allegations of Paragraphs 1 through 13, above.
`16. As a result of defendant’s wrongful actions as set forth above,
`Burningham has been damaged in an amount to be shown according to proof, and
`accordingly is entitled to benefits under the Wine Group Health Plan, and an
`enforcement of her rights in that regard.
`17. As a result of the dispute and disagreement explained above, it has
`become necessary for Burningham to retain an attorney to enforce her rights under
`ERISA. Plaintiff therefore is entitled to an award of reasonable attorney fees and
`costs under ERISA, 29 U.S.C. § 1132(g)(1).
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`4 Complaint
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`Case 2:22-cv-00659-TLN-AC Document 1 Filed 04/13/22 Page 5 of 5
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`4.
`5.
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`For reasonable attorney fees and costs of suit; and
`For such other and further relief as the Court deems just and proper.
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`WHEREFORE, plaintiff TRACY BURNINGHAM prays for judgment
`against defendant THE WINE GROUP, INC. HEALTH BENEFIT PLAN as
`follows:
`For a judicial declaration of the parties’ respective rights, obligations
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`1.
`and liabilities, relative to the matters referred to in Paragraph 13, above;
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`2.
`For an enforcement of plaintiff’s rights in that regard, relative to the
`matters referred to in Paragraph 16, above;
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`3.
`For employee benefits, if any, ancillary to the disability benefits at
`issue;
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`Dated: April 13, 2022
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`LAW OFFICE OF ROBERT F. KEEHN
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`By: _____________________________
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`Robert F. Keehn, Esq.
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`Attorney for Plaintiff
`Tracy Burningham
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`5 Complaint
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