Case 3:21-cv-08082-JCS Document 1 Filed 10/15/21 Page 1 of 10
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`
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`David M. Lilienstein, SBN 218923
`david@dllawgroup.com
`Katie J. Spielman, SBN 252209
`katie@dllawgroup.com
`DL LAW GROUP
`345 Franklin St.
`San Francisco, CA 94102
`Telephone: (415) 678-5050
`Facsimile: (415) 358-8484
`
`Attorneys for Plaintiff,
`STANLEY S.
`
`
`UNITED STATES DISTRICT COURT
`NORTHERN DISTRICT OF CALIFORNIA
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`STANLEY S.
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`
`
`v.
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`AETNA LIFE INSURANCE
`COMPANY; PLAYWORKS
`EDUCATION ENERGIZED;
`PLAYWORKS WELFARE BENEFITS
`PLAN; and DOES 1 through 10,
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`
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`Plaintiffs,
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`Defendants.
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` Case No.
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`PLAINTIFF STANLEY S.’S COMPLAINT
`FOR BREACH OF THE EMPLOYEE
`RETIREMENT INCOME SECURITY
`ACT OF 1974 (ERISA); BREACH OF
`FIDUCIARY DUTY; ENFORCEMENT
`AND CLARIFICATION OF RIGHTS;
`PREJUDGMENT AND POSTJUDGMENT
`INTEREST; AND ATTORNEYS’ FEES
`AND COSTS
`
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`Plaintiff, STANLEY S. herein sets forth the allegations of this Complaint against
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`Defendants AETNA LIFE INSURANCE COMPANY; PLAYWORKS EDUCATION
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`ENERGIZED; PLAYWORKS WELFARE BENEFITS PLAN (“the Plan”) and DOES 1 through
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`10.
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`PRELIMINARY ALLEGATIONS
`JURISDICTION
`Plaintiff brings this action for relief pursuant to Section 502(a)(1)(B) and (a)(3)
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`1.
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`of the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. Section 1132(a)(1)(B),
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`COMPLAINT
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`1
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`CASE NO.
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`

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`Case 3:21-cv-08082-JCS Document 1 Filed 10/15/21 Page 2 of 10
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`and (a)(3). This Court has subject matter jurisdiction over Plaintiff’s claim pursuant to ERISA
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`Section 502 (e), (f) and (g), 29 U.S.C. Section 1132 (e), (f), and (g) and 28 U.S.C. Section 1331
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`as it involves a claim made by Plaintiff for employee benefits under an employee benefit plan
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`regulated and governed under ERISA. Jurisdiction is predicated under these code sections as
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`well as 28 U.S.C. Section 1331 as this action involves a federal question.
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`2.
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`This action is brought for the purpose of recovering benefits under the terms of
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`an employee benefit plan, and enforcing Plaintiff’s rights under the terms of an employee
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`benefit plan named as a Defendant.
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`3.
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`Plaintiff seeks relief, including but not limited to: past mental health benefits in
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`the correct amount related to Defendants’ improper denial of Plaintiff’s claim; prejudgment and
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`post judgment interest; general and special damages; and attorneys’ fees and costs; and any
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`other form of equitable relief that may arise during the pendency of this action and that the
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`Court may deem appropriate.
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`PARTIES
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`4.
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`5.
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`Plaintiff is and at all times relevant was a resident of the State of California.
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`At all relevant times, STANLEY S. participated in an employee welfare benefit
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`plan, PLAYWORKS WELFARE BENEFITS PLAN, (“the Plan”) within the meaning of
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`ERISA section 3(1), 29 U.S.C. § 1002(1), sponsored by his employer, Defendant
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`PLAYWORKS EDUCATION ENERGIZED.
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`6.
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`At all relevant times, AETNA LIFE INSURANCE COMPANY (“Aetna”) was
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`and is a corporation whose primary place of business is located in the State of California.
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`7.
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`Mental Health claims under the Plan were at all relevant times administered by
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`Aetna and/or its third-party designee.
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`8.
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`A.D. is STANLEY S.’s child and a Plan beneficiary.
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`COMPLAINT
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`2
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`CASE NO.
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`Case 3:21-cv-08082-JCS Document 1 Filed 10/15/21 Page 3 of 10
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`9.
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`A.D. is a male-to-female transgender adolescent, hereinafter referred to by the
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`pronouns she/her/hers.
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`10. At all relevant times, the Plan was an insurance plan that offered, inter alia,
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`mental health benefits to employees and their beneficiaries, including Plaintiff. This action
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`involves mental health claims denied by the Plan’s claim administrator.
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`FACTS
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`11.
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`The Plan guarantees, warrants, and promises coverage for medically necessary
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`health care services, care and treatment, including but not limited to: health care services,
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`mental health care, and the treatment at issue herein.
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`12. At all relevant times A.D. was a beneficiary of the Plan, and the Plan was in full
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`force and effect.
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`13.
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`The Summary Plan Description defines Medically Necessary services as services
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`as
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`Health care services that a provider exercising prudent clinical judgment, would
`provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an
`illness, injury, disease or its symptoms, and that are:
`In accordance with generally accepted standards of medical practice
`•
`• Clinically appropriate, in terms of type, frequency, extent, site and duration,
`and considered effective for the patient’s illness, injury or disease
`• Not primarily for the convenience of the patient, physician, or other health
`care provider
`• Not more costly than an alternative service or sequence of services at least as
`likely to produce equivalent therapeutic or diagnostic results as to the diagnosis
`or treatment of that patient’s illness, injury or disease
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`14.
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`The Plan contemplates treatment for participants and beneficiaries in a
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`residential treatment center.
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`15.
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`The Plan covers mental health expenses and services including “Inpatient room
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`and board at the semi-private room rate, and other services and supplies related to your
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`condition that are provided during your stay in a hospital, psychiatric hospital, or residential
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`treatment facility.”
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`COMPLAINT
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`3
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`CASE NO.
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`Case 3:21-cv-08082-JCS Document 1 Filed 10/15/21 Page 4 of 10
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`16.
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`California’s Mental Health Parity Act, Health & Safety Code §1374.72, as well as the
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`Federal Mental Health Parity and Addictions Equity Act of 2008 (“MHPAEA”) specifically require that
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`health care plans provide medically necessary diagnosis, care and treatment for the treatment of specified
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`mental health illnesses at a level equal to the provision of benefits for physical illnesses.
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`17. A.D. was diagnosed with, inter alia, gender dysphoria, depression, anxiety, ADHD, eating
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`disorder, and substance use.
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`18. At a young age, A.D. began displaying severe behavioral problems at home and
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`at school.
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`19.
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`In pre-school, A.D. was found being sexual with another peer in the bathroom
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`and, on another occasion, was found smearing excrement on the bathroom wall.
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`20.
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`In 6th grade, A.D. began eating compulsively and also questioning her gender
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`identity. She began seeing a therapist who specializes in adolescents and gender identity.
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`21. A.D. eventually exhibited episodes of violence and manipulation, at one time
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`punching her father in the face and then calling the police to report child abuse.
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`22. After it was reported to her parents that A.D. had suicidal ideations, she was
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`admitted to Edgewood Center for Children and Families Crisis Stabilization Unit (CSU).
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`23. A.D. continued seeing her therapist, participated in dialectical behavioral therapy
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`(DBT), and began seeing a psychiatrist, who prescribed her Zoloft.
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`24. Despite this ongoing treatment, A.D.’s mental health continued to deteriorate.
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`Family members had to sleep with doors locked out of fear A.D. would become violent. A
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`parent had to work from home every day so A.D. was supervised and remained safe.
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`25. A.D. made death threats to others at school.
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`26. A.D. was again placed in the CSU again after a box of chemicals was found in
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`her backpack along with a note saying she wanted to kill everyone at her school.
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`COMPLAINT
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`4
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`CASE NO.
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`Case 3:21-cv-08082-JCS Document 1 Filed 10/15/21 Page 5 of 10
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`27.
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`Following her CSU stay, A.D. was admitted to a partial hospitalization program
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`at the Edgewood Center.
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`28.
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`The treatment at Edgewood lasted ten days. However, upon her return home
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`each evening A.D. engaged in self-harm and made threats of violence to others.
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`29. As a result of A.D.’s failed outpatient therapy, her ongoing suicidality and/or
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`homicidal threats, and the ineffectiveness of A.D.’s medications, her treating mental health
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`providers unanimously recommended that A.D. be treated at a residential treatment facility that
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`offered 24/7 supervision and treatment. A.D. was then admitted to the Elevations Residential
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`Treatment Center (“Elevations”).
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`30. At all times relevant, A.D.’s treatment at Elevations was medically necessary,
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`based upon the reasoned medical opinions of A.D.’s mental health providers.
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`31.
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`Plaintiff filed claims for mental health benefits with Defendants for A.D.’s
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`treatment at Elevations.
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`32. Aetna and/or Aetna’s contracted utilization review service provider initially
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`approved Plaintiff’s claims for treatment, for approximately six weeks.
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`33. Aetna and/or Aetna’s contracted utilization review service provider, however,
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`then denied Plaintiff’s claims for continued treatment at Elevations.
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`34.
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`Individuals, and particularly adolescents, who reach the point where prior
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`outpatient modalities of therapy no longer work, and who require inpatient treatment at an
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`inpatient, residential, facility, on average require treatment periods of between six months to
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`eighteen months.
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`35.
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`The required treatment period at a residential treatment facility increases where,
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`as herein, the patient suffers from multiple, co-morbid, mental health conditions.
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`36.
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`Plaintiff timely appealed Aetna’s claim denials.
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`COMPLAINT
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`5
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`CASE NO.
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`37. Aetna both individually and by and through its utilization review service
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`provider, on behalf of the Plan, denied Plaintiff’s appeal.
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`38.
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`Plaintiff submitted a level two appeal.
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`39. Aetna both individually and by and through its utilization review service
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`provider, on behalf of the Plan, denied Plaintiff’s level two appeal.
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`40.
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`The level of care guidelines used by Aetna to deny A.D.’s care fall below
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`reasonable standards of care in the medical community, as explained by the court in Wit v.
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`United Behavioral Health, 2019 WL 1033730 (N.D.Cal. March 5, 2019).
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`41. Aetna breached the generally accepted standard of care herein by failing to
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`accept and consider that treatment is not limited to simply alleviating an individual’s current
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`mental health symptoms, and by ignoring and failing to consider the long-term, chronic nature
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`of A.D.’s mental health needs.
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`42. Aetna breached the generally accepted standard of care herein by failing to
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`accept and consider that effective treatment of co-morbid or co-occurring behavioral health
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`disorders requires consideration of the interaction of these disorders, and the implications of
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`these disorders on determining the proper and appropriate level of care.
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`43. Aetna breached the generally accepted standard of care herein by failing to
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`accept and consider that where there is ambiguity over the proper level of care, that
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`practitioners should err on the side of caution and should place patients in the higher level of
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`care.
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`44. Aetna breached the generally accepted standard of care herein by improperly
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`focusing on acute symptomology and failing to consider that the same level of care is needed
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`when an acute crisis has passed, and by failing to consider the likelihood of regression and risk
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`of further acute symptomology.
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`COMPLAINT
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`CASE NO.
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`45. All of the above failures, inter alia, constitute an abuse of discretion by Aetna in
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`the handling of A.D.’s claims for mental health care and treatment.
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`46. As a result, Plaintiff was forced to pay for A.D.’s care and treatment at
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`Elevations from his own personal funds.
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`47.
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`Plaintiff has exhausted all administrative remedies regarding the denial of A.D.’s
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`mental health benefits.
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`CLAIMS FOR RELIEF
`FIRST CAUSE OF ACTION
`Recovery of Benefits Due Under an ERISA Benefit Plan
`(Against AETNA LIFE INSURANCE COMPANY; PLAYWORKS EDUCATION
`ENERGIZED; PLAYWORKS WELFARE BENEFITS PLAN; and DOES 1-10 For Plan
`Benefits, Enforcement and Clarification of Rights, Prejudgment and Post Judgment
`Interest, and Attorneys’ Fees and Costs, Pursuant to ERISA Section 502(a)(1)(B), 29
`U.S.C. Section 1132(a)(1)(B))
`Plaintiff incorporates all preceding paragraphs of this Complaint as though fully
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`48.
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`set forth herein.
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`49.
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`ERISA Section 502(a)(1)(B), 29 U.S.C. Section 1132(a)(1)(B) permits a plan
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`participant to bring a civil action to recover benefits due under the terms of the plan and to
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`enforce Plaintiff’s rights under the terms of a plan.
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`50. At all relevant times, Plaintiff, and his child, A.D. were insured under the health
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`care plan at issue herein. At all relevant times, A.D. met the medical necessity criteria for
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`treatment required under the terms and conditions of the Plan.
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`51.
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`By denying Plaintiff’s mental health claim, Defendants have violated, and
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`continue to violate, the terms of the Plan, the terms of ERISA, and Plaintiff’s rights thereunder.
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`52.
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`The provisions of an ERISA plan should be construed so as to render none
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`nugatory and to avoid illusory promises.
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`COMPLAINT
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`7
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`CASE NO.
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`Case 3:21-cv-08082-JCS Document 1 Filed 10/15/21 Page 8 of 10
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`SECOND CAUSE OF ACTION
`Breach of Fiduciary Duty Under ERISA § 502(a)(3), 29 U.S.C. Section 1132(a)(3)
`(against Defendants AETNA LIFE INSURANCE COMPANY; PLAYWORKS EDUCATION
`ENERGIZED; PLAYWORKS WELFARE BENEFITS PLAN; DOES 1-10)
`Plaintiff incorporates all preceding paragraphs of this Complaint as though fully set forth
`herein.
` ERISA § 404(a)(1)(A), 29 U.S.C. § 1104(a)(1)(A), requires fiduciaries to
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`53.
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`54.
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`discharge their duties solely in the interests of employee benefit plan participants and
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`beneficiaries and for the exclusive purpose of providing benefits and defraying reasonable
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`expenses of administering the plan.
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`55.
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` ERISA § 404(a)(1)(B), 29 U.S.C. § 1104(a)(1)(B), requires fiduciaries to
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`discharge their duties with the care, skill, prudence, and diligence under the circumstances then
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`prevailing that a prudent man acting in like capacity and familiar with such matters would use in
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`the conduct of an enterprise of a like character and with like aims.
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`56.
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` ERISA § 404(a)(1)(D), 29 U.S.C. § 1104(a)(1)(D), requires fiduciaries to
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`discharge their duties in accordance with the documents and instruments governing the plan
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`insofar as such documents and instruments are consistent with the provisions of ERISA.
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`57.
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` In committing the acts and omissions herein alleged, Defendants breached their
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`fiduciary duties in violation of ERISA §§ 404(a)(1)(A), (B) and (D), 29 U.S.C. §§
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`1104(a)(1)(A)(B) and (D).
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`58.
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`Plaintiff is further informed and believes, and thereon alleges, that Defendants
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`have approved identical or comparable benefits to other participants under circumstances similar
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`to those of the Plaintiff. The failure to provide benefits to Plaintiff when they have done so for
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`other Plan participants in similar circumstances constitutes a breach of fiduciary duties in
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`violation of ERISA §§ 404(a)(1)(A) and (B), 29 U.S.C. §§ 1104(a)(1)(A) and (B).
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`COMPLAINT
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`8
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`CASE NO.
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`59. As a result of Defendants’ breaches of fiduciary duty, Plaintiff has been harmed,
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`and the Defendants have been permitted to retain assets and generate earnings on those assets to
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`which Defendants were not entitled.
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`60.
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` Wherefore, Plaintiff is entitled to appropriate equitable relief including but not
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`limited to injunction, disgorgement, and surcharge.
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`PRAYER FOR RELIEF
`AS TO ALL DEFENDANTS
`WHEREFORE, Plaintiff prays that the Court grant the following relief:
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`61. Declare that Defendants, and/or each of them, violated the terms of the Plan by failing to
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`provide mental health benefits;
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`62. Order Defendants, and/or each of them, to pay the mental health benefits due, together
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`with prejudgment interest on each and every such benefit payment through the date of judgment at the
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`rate of 9% compounded;
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`63.
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`For appropriate equitable relief pursuant to ERISA § 502(a)(3), 29 U.S.C. §
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`1132(a)(3), including but not limited to a declaration of Plaintiff’s rights hereunder with respect
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`to Defendants AETNA LIFE INSURANCE COMPANY; PLAYWORKS EDUCATION
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`ENERGIZED; PLAYWORKS WELFARE BENEFITS PLAN; an injunction against further
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`failure to provide like benefits; injunctive relief requiring Defendants to adjudicate claims for
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`mental and behavioral health benefits utilizing generally accepted standards of care; removal of
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`Aetna as a Plan fiduciary; disgorgement of any profits or ill gotten gain realized by any
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`Defendants; and surcharge for any pecuniary injuries Plaintiff has suffered as a consequence of
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`Defendants’ breaches of their ERISA fiduciary duties;
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`64. Award Plaintiff reasonable attorneys’ fees and costs of suit incurred herein pursuant to
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`ERISA Section 502(g), 29 U.S.C. Section 1132(g);
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`65.
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`Provide such other relief as the Court deems equitable and just.
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`COMPLAINT
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`9
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`CASE NO.
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`Case 3:21-cv-08082-JCS Document 1 Filed 10/15/21 Page 10 of 10
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`AS TO ALL CAUSES OF ACTION: For such other and further relief as the Court deems just and
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`proper.
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`Dated: October 14, 2021
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`Respectfully submitted,
`DL LAW GROUP
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`By: /s/ David M. Lilienstein
`David M. Lilienstein
`Katie J. Spielman
`Attorneys for Plaintiff, STANLEY S.
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`___
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`COMPLAINT
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`10
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`CASE NO.
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