Case 3:22-cv-02537-LB Document 1 Filed 04/26/22 Page 1 of 12
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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,
`STEVEN P.
`
`
`UNITED STATES DISTRICT COURT
`NORTHERN DISTRICT OF CALIFORNIA
`
`
`STEVEN P.
`
`
`
`v.
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`ANTHEM BLUE CROSS LIFE AND
`HEALTH INSURANCE COMPANY;
`AMN HEALTHCARE SERVICES, INC.,
`and DOES 1 through 10,
`
`
`
`
`
`
`
`
`Plaintiff,
`
`Defendants.
`
` Case No.
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`PLAINTIFF STEVEN P.’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
`
`
`
`
`Plaintiff, STEVEN P. herein sets forth the allegations of this Complaint against
`Defendants ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY
`(“ANTHEM”); AMN HEALTHCARE SERVICES, INC.; and DOES 1 through 10.
`//
`//
`//
`//
`//
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`COMPLAINT
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`CASE NO.
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`Case 3:22-cv-02537-LB Document 1 Filed 04/26/22 Page 2 of 12
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`PRELIMINARY ALLEGATIONS
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`JURISDICTION
`Plaintiff brings this action for relief pursuant to Section 502 (a) (1) (B) and Section 502
`1.
`(a) (3) of the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. Section 1132 (a) (1)
`(B). This Court has subject matter jurisdiction over Plaintiff’s claim pursuant to ERISA Section 502
`(e) and (f), 29 U.S.C. Section 1132 (e), (f), and (g) and 28 U.S.C. Section 1331 as it involves a claim
`made by Plaintiff for employee benefits under an employee benefit plan regulated and governed under
`ERISA. Jurisdiction is predicated under these code sections as well as 28 U.S.C. Section 1331 as this
`action involves a federal question.
`This action is brought for the purpose of recovering benefits under the terms of an
`2.
`employee benefit plan and enforcing Plaintiff’s rights under the terms of an employee benefit plan.
`Plaintiff seeks relief, including but not limited to: past mental health benefits in the
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`correct amount related to Defendant’s improper denial of Plaintiff’s claim; prejudgment and post
`judgment interest; general and special damages; and attorneys’ fees and costs.
`PARTIES
`At all relevant times, Plaintiff STEVEN P. participated in the AMN HEALTHCARE
`4.
`SERVICES CORPORATE HSA (“the Plan”), an employee welfare benefit plan within the meaning of
`ERISA section 3(1), 29 U.S.C. § 1002(1), sponsored by his employer, Defendant AMN
`HEALTHCARE SERVICES, INC. (“AMN”).
`The designated “Claims Administrator” under the Plan for mental health benefits was at
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`all relevant times Defendant ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE
`COMPANY(“Anthem”).
`Anthem is a health insurance provider authorized to transact and currently transacting
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`the business of insurance in the State of California.
`AMN was the Plan Administrator.
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`COMPLAINT
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`2
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`CASE NO.
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`Case 3:22-cv-02537-LB Document 1 Filed 04/26/22 Page 3 of 12
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`At all relevant times, the Plan was an insurance plan that offered, inter alia, mental
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`health benefits to employees and their beneficiaries, including Plaintiff. This action involves mental
`health claims denied by the Plan’s claims administrator.
`FACTS
`The Plan guarantees, warrants, and promises “Mental Health Services” for members and
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`their beneficiaries, including but not limited to: health care services, mental health care, and treatment
`at issue herein.
`S.P. is STEVEN P.’s daughter, and was, at all relevant times, a beneficiary of the Plan.
`10.
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`At all relevant times, the Plan was in full force and effect.
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`The Plan guarantees, promises, and warrants benefits for medically necessary covered
`health care services.
`The Plan defines “Medically Necessary” health care services as those
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`that a Physician, exercising professional 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, and
`• Not more costly than an alternative services, including no service or the same
`service in an alternative setting or sequence of services that is medically
`appropriate and is likely to produce equivalent therapeutic or diagnostic results
`as to the diagnosis or treatment of that patient’s injury, disease, illness or
`condition. For example, the Plan will not provide coverage for an inpatient
`admission for surgery if the surgery could have been performed on an outpatient
`basis or an infusion or injection of a specialty drug provided in the outpatient
`department of a hospital if the drug could be provided in a Physician’s office of
`the home setting.
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`The Plan guarantees coverage for inpatient and outpatient treatment of mental
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`health conditions.
`California’s Mental Health Parity Act, Health & Safety Code §1374.72 and Insurance
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`Code § 10144.5, as well as the Federal Mental Health Parity and Addictions Equity Act of 2008
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`COMPLAINT
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`3
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`CASE NO.
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`(“MHPAEA”) specifically require that health care plans provide medically necessary diagnosis, care
`and treatment for the treatment of specified mental health illnesses at a level equal to the provision of
`benefits for physical illnesses.
`S.P. has a long history of mental illness and emotional disturbance, beginning at a young
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`age.
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`Around sixth grade, S.P. was diagnosed with severe ADHD for which she was
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`prescribed medication. She began seeing a psychiatrist and a therapist.
`Despite ongoing treatment, S.P.’s condition continued to worsen. In 2017, S.P.’s mom
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`found a note saying that S.P. planned to commit suicide. She was subsequently admitted to the
`emergency department and then, to Sundance Behavioral Health Hospital, an inpatient treatment center,
`for seven days.
`19. When S.P. returned home, she continued outpatient treatment, but her condition
`continued to worsen. She began cutting herself.
`Eventually, S.P.’s suicidal ideation and threats escalated to the point that she was again
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`admitted to the emergency department, and from there, the children’s psychiatric unit at Children’s
`Medical Center in Dallas.
`After her discharge from Children’s Medical Center, S.P. participated in an intensive
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`DBT program. She participated in individual and group DBT counseling and received individual
`therapy several times a week. She continued taking psychiatric medication.
`Despite ongoing treatment, S.P.’s self-harm behavior continued to escalate. She would
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`bang her head against walls and floors and punch herself. S.P.’s destructive behavior escalated to the
`point that she once again was admitted to the emergency department and then to the children’s
`psychiatric unit at Children’s Medical Center.
`Again, after her discharge S.P. resumed outpatient treatments. Again, her condition
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`deteriorated to the point that she was unmanageable at home.
`//
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`COMPLAINT
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`4
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`CASE NO.
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`Case 3:22-cv-02537-LB Document 1 Filed 04/26/22 Page 5 of 12
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`A. Anthem’s Wrongful Denials of S.P.’s Treatment at New Vision Wilderness
`As a result of S.P.’s escalating dangerous behavior and the repeated failure of every
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`other treatment modality, S.P. was admitted to New Vision Wilderness (“New Vision”), an outdoor
`behavioral health program.
`At all times relevant, S.P.’s treatment at New Vision was medically necessary, based
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`upon the reasoned medical opinions of her treaters.
`At all times relevant, S.P.’s treatment at New Vision was a covered benefit under the
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`Plan.
`
`Plaintiff filed claims for mental health benefits pursuant to the terms of the Plan for
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`S.P.’s treatment at New Vision.
`Anthem denied Plaintiff’s claims for S.P.’s treatment at New Vision.
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`Plaintiff timely appealed Anthem’s denials of S.P.’s claims for treatment at New Vision.
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`Anthem denied Plaintiff’s appeals.
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`As a result, Plaintiff was forced to pay for S.P.’s care and treatment at New Vision from
`his own personal funds.
`Plaintiff has exhausted all administrative remedies regarding the denial of S.P.’s
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`mental health benefits for her treatment at New Vision.
`B. Anthem’s Wrongful Denials of S.P.’s Treatment at ViewPoint Center, LLC
`Following S.P.’s treatment at New Vision, at the recommendation of her treatment
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`providers, she was admitted to Summit Achievement of Stow, a residential treatment center in Maine.
`From there, S.P. returned home briefly.
`34. While home, S.P. got into an explosive argument with her family which led to the police
`being called. Shortly thereafter, S.P. attended a private boarding school.
`35. While at the boarding school, S.P.’s condition deteriorated. She threatened suicide. The
`school kept S.P. sequestered and could not provide the level of care S.P. needed.
` At the recommendation of her treatment providers, S.P. was admitted to Sedona Sky
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`Academy (“Sedona Sky”), a residential treatment center.
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`COMPLAINT
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`CASE NO.
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`Case 3:22-cv-02537-LB Document 1 Filed 04/26/22 Page 6 of 12
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`37. While at Sedona Sky, S.P. ran away from the facility, stating she wanted to kill herself,
`verbally abused staff following her, and refused to return to the facility. The police had to forcibly
`place her in the squad car and take her to a local hospital, Verde Valley Medical Center (“Verde
`Valley”) where she was treated in the emergency department.
`The staff at Verde Valley recommended an inpatient behavioral health hospital for S.P.
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`At the recommendation of her treatment providers, S.P. was admitted to ViewPoint
`Center, LLC (“ViewPoint”), a residential treatment center.
`At all times relevant, S.P.’s treatment at ViewPoint was medically necessary, based
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`upon the reasoned medical opinions of her treaters.
`At all times relevant, S.P.’s treatment at ViewPoint was a covered benefit under the
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`Plan.
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`Plaintiff filed claims for mental health benefits pursuant to the terms of the Plan for
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`S.P.’s treatment at ViewPoint.
`Anthem denied Plaintiff’s claims for S.P.’s treatment at ViewPoint, claiming S.P.’s
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`treatment was not medically necessary.
`Plaintiff timely appealed Anthem’s denials of S.P.’s claims for treatment at ViewPoint.
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`Anthem denied Plaintiff’s appeals.
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`In denying Plaintiff’s claim for care and treatment for S.P. at ViewPoint, Anthem, by and
`through the Plan, used MCG “level of care guidelines” that are unfair and biased against approving
`claims for residential treatment such as are at issue herein, and that do not reflect reasonable standards in
`the medical community.
`The level of care guidelines used by Anthem, by and through the Plan, to deny S.P.’s care
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`fall below reasonable standards of care in the medical community.
`Anthem, by and through the Plan, breached the generally accepted standard of care herein
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`by failing to accept and consider that treatment is not limited to simply alleviating an individual’s
`current mental health symptoms, and by ignoring and failing to consider the long-term, chronic nature of
`S.P.’s mental health needs.
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`COMPLAINT
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`CASE NO.
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`Anthem, by and through the Plan, breached the generally accepted standard of care herein
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`by failing to accept and consider that effective treatment of co-morbid, or co-occurring behavioral health
`disorders requires consideration of the interaction of these disorders, and the implications of these
`disorders on determining the proper and appropriate level of care.
`Anthem, by and through the Plan, breached the generally accepted standard of care herein
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`by failing to accept and consider that where there is ambiguity over the proper level of care, that
`practitioners should err on the side of caution and should place patients in the higher level of care.
`Anthem, by and through the Plan, breached the generally accepted standard of care herein
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`by improperly focusing on acute symptomology and failing to consider that the same level of care is
`needed when an acute crisis has passed, and by failing to consider the likelihood of regression and risk
`of further acute symptomology.
`Anthem’s use, by and through the Plan, of insurer-generated, proprietary guidelines
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`violated the California Mental Health Parity Act.
`As a result, Plaintiff was forced to pay for S.P.’s care and treatment at ViewPoint from
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`his own personal funds.
`Plaintiff has exhausted all administrative remedies regarding the denial of S.P.’s
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`mental health benefits for her treatment at ViewPoint.
`C. Anthem’s Wrongful Denials of S.P.’s Treatment at Skyland Trail
`At the recommendation of her treatment providers, following her treatment at
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`ViewPoint, S.P. was admitted to Skyland Trail, a residential treatment center.
` Plaintiff filed claims for mental health benefits pursuant to the terms of the Plan for
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`S.P.’s treatment at Skyland Trail.
`Anthem initially approved Plaintiff’s claims for S.P.’s treatment at Skyland Trail.
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`Anthem approved two weeks of treatment.
`Anthem denied Plaintiff’s claims for the remainder of S.P.’s treatment at Skyland Trail,
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`claiming S.P.’s treatment was not medically necessary.
`Plaintiff timely appealed Anthem’s denials of S.P.’s claims for treatment at Skyland
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`Trail.
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`COMPLAINT
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`CASE NO.
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`Anthem denied Plaintiff’s appeals.
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`As a result, Plaintiff was forced to pay for S.P.’s care and treatment at Skyland Trail from
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`his own personal funds.
`Plaintiff has exhausted all administrative remedies regarding the denial of S.P.’s
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`mental health benefits for her treatment at Skyland Trail.
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`CLAIMS FOR RELIEF
`FIRST CAUSE OF ACTION
`Recovery of Benefits Due Under an ERISA Benefit Plan
`(Against BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (“ANTHEM”); AMN
`HEALTHCARE SERVICES, INC.; DOES 1-10; 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 set forth
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`herein.
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`ERISA Section 502(a)(1)(B), 29 U.S.C. Section 1132(a)(1)(B) permits a plan participant
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`to bring a civil action to recover benefits due under the terms of the plan and to enforce Plaintiff’s
`rights under the terms of a plan.
`At all relevant times, Plaintiff and his daughter S.P. were insured under the health care
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`plan at issue herein, and Plaintiff’s daughter S.P. met the covered health services and medical necessity
`criteria for treatment required under the terms and conditions of the Plan.
`By denying Plaintiff’s mental health claims for S.P.’s treatment at New Vision,
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`ViewPoint, and Skyland Trail, Defendants have violated, and continue to violate, the terms of the Plan,
`the terms of ERISA, and Plaintiff’s rights thereunder.
`The provisions of an ERISA plan should be construed so as to render none nugatory and
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`to avoid illusory promises.
`//
`//
`//
`//
`//
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`COMPLAINT
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`CASE NO.
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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 ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY
`(“ANTHEM”); AMN HEALTHCARE SERVICES, INC.; DOES 1-10)
`Plaintiff incorporates all preceding paragraphs of this Complaint as though fully set
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`forth herein.
` At all material times herein, Defendants, and each of them, were fiduciaries with
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`respect to their exercise of authority over the management of the Policy, disposition of Plan assets, and
`administration of the Policy.
`Plaintiff asserts that a claim for benefits due under the Policy does not provide him with
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`an adequate remedy at law in light of Defendants’ continuing course of conduct in violating the terms of
`the Policy and applicable law as described below.
`ERISA § 404(a)(1)(A), 29 U.S.C. § 1104(a)(1)(A), requires fiduciaries to discharge their
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`duties solely in the interests of employee benefit plan participants and beneficiaries and for the exclusive
`purpose of providing benefits and defraying reasonable expenses of administering the plan.
` ERISA § 404(a)(1)(B), 29 U.S.C. § 1104(a)(1)(B), requires fiduciaries to discharge their
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`duties with the care, skill, prudence, and diligence under the circumstances then prevailing that a
`prudent man acting in like capacity and familiar with such matters would use in the conduct of an
`enterprise of a like character and with like aims.
` ERISA § 404(a)(1)(D), 29 U.S.C. § 1104(a)(1)(D), requires fiduciaries to discharge their
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`duties in accordance with the documents and instruments governing the plan insofar as such documents
`and instruments are consistent with the provisions of ERISA.
` In committing the acts and omissions herein alleged, Defendants breached their fiduciary
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`duties in violation of ERISA §§ 404(a)(1)(A), (B) and (D), 29 U.S.C. §§ 1104(a)(1)(A)(B) and (D).
`At all material times herein, Defendants, and each of them, violated these duties
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`by, inter alia, the following:
`A.
`Consciously, unreasonably, intentionally, and without justification, failing to
`disclose to plan participants their use of MCG “level of care guidelines” that are unfair
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`COMPLAINT
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`CASE NO.
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`and biased against approving claims for residential treatment such as are at issue herein,
`and that do not reflect reasonable standards in the medical community;
`B.
`Consciously, unreasonably, intentionally, and without justification, violating
`California’s Mental Health Parity Act, Health & Safety Code §1374.72, as well as the
`Federal Mental Health Parity and Addictions Equity Act of 2008 (“MHPAEA”) which
`specifically require that health care plans provide medically necessary diagnosis, care and
`treatment for the treatment of specified mental health illnesses at a level equal to the
`provision of benefits for physical illnesses;
`C.
`Consciously and unreasonably failing to investigate all bases upon which to pay
`and honor Plaintiff’s claim, and related claims and/or similar claims, for benefits, and
`consciously and unreasonably failing to investigate all bases to support coverage fairly
`and in good faith and refusing to give Plaintiff’s interests or the interests of the Plan at
`least as much consideration as they gave their own;
`D.
`Consciously and unreasonably asserting improper bases for denying full payment
`of Plaintiff’s claim, and related claims and/or similar claims, for mental health care
`benefits;
`E.
`Consciously and unreasonably interpreting the Plan in a manner designed to deny
`and minimize benefits and in a manner that thwarts the reasonable expectations of the
`Plan’s beneficiaries and participants in order to maximize its own profits and minimize
`the benefits that it pays claimants;
`F.
`Consciously and unreasonably refusing to pay Plaintiff’s claim, and related claims
`and/or similar claims, with the knowledge that Plaintiff’s claim and similar claims are
`payable and with the intent of boosting profits at Plaintiff’s and other claimants’ expense;
`and
`Consciously and unreasonably failing to follow the terms of the Plan and
`G.
`applicable regulations governing the administration of claims, and the review of denied
`claims; and
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`COMPLAINT
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`10
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`CASE NO.
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`Using medical directors who have no training, expertise or Board Certification in
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`mental and or behavioral health to deny mental health claims and opine on medical
`necessity; and or having said medical directors farm out all mental health decision-
`making to third party reviewers, and then rubber-stamping the opinions of said third party
`reviewers with no independent review, oversight or medical expertise;
`As a result of Defendants’ breaches of fiduciary duty, Plaintiff has been harmed, and the
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`Defendants have been permitted to retain assets and generate earnings on those assets to which
`Defendants were not entitled.
`Plaintiff further requests judgment permanently enjoining Defendant Anthem Blue Cross
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`Life and Health Insurance Company from ever again serving as a fiduciary with respect to the Plan,
`together with attorneys’ fees and cost; and enjoining the Plan from using level of care guidelines that fall
`below reasonable standards in the medical community, either as written or as applied, or both. In
`addition, Plaintiff seeks appropriate equitable relief from all Defendants, and each of them, including an
`order by this Court that, based upon principles of waiver and/or estoppel, Plaintiff is entitled to benefits
`in the amount of the cost of S.P.’s treatment at New Vision, ViewPoint, and Skyland Trail. In addition,
`Plaintiff seeks disgorgement of profits, make-whole relief, and that Plaintiff be placed in the position
`that he would have been in had he been paid the full amount of benefits to which he is entitled,
`including, without limitation, interest, attorneys’ fees and other losses resulting from Defendants’
`breach.
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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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`53. Declare that Defendants, and/or each of them, violated the terms of the Plan by failing to
`provide mental health benefits;
`54. Order Defendants, and/or each of them, to pay the mental health benefits due, together
`with prejudgment interest on each and every such benefit payment through the date of judgment at the
`rate of 9% compounded;
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`COMPLAINT
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`CASE NO.
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`55. Award Plaintiff reasonable attorneys’ fees and costs of suit incurred herein pursuant to
`ERISA Section 502(g), 29 U.S.C. Section 1132(g);
`56.
`Order that Defendants cease using their current level of care guidelines to evaluate claims
`involving mental health treatment;
`Order that, to the extent Defendants evaluate mental health claims using level of care
`57.
`guidelines, that it use publicly available level of care guidelines;
`Order that, to the extent Defendants use level of care guidelines to evaluate mental health
`58.
`claims, that Defendants provide copies of the guidelines to all claimants whose claims are denied, along
`with the specific section(s) of the guidelines it relied upon;
`Order that each fiduciary found liable for breaching his/her/its duties to disgorge any
`59.
`profits made through the denial of medically necessary claims through the use of inconsistent care
`guidelines. This includes, but is not limited to, any violation of ERISA §§ 404 and 406;
`For appropriate equitable relief pursuant to 29 U.S.C. §§ 1132(a)(2) and (a)(3), including
`60.
`but not limited to, a declaration of Plaintiff’s rights to a full and fair review under ERISA, and a
`declaration of Plan participants’ and beneficiaries’ rights to a full and fair review;
`Removal of Anthem Blue Cross Life and Health Insurance Company as a Plan fiduciary;
`61.
`62.
`For surcharge relief;
`63.
`An injunction against further denial of Plaintiff’s benefits pursuant to 29 U.S.C. §§
`1132(a)(3);
`64.
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`Provide such other relief as the Court deems equitable and just.
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`Dated: April 26, 2022
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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, STEVEN P.
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`___
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`COMPLAINT
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`12
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`CASE NO.
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`6
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