Case 5:22-cv-02566 Document 1 Filed 04/27/22 Page 1 of 7
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`Lisa S. Kantor, State Bar No. 110678
`lkantor@kantorlaw.net
`Peter S. Sessions, State Bar No. 193301
`psessions@kantorlaw.net
`KANTOR & KANTOR, LLP
`19839 Nordhoff Street
`Northridge, CA 91324
`Telephone: (818) 886-2525
`Facsimile: (818) 350-6272
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`Attorneys for Plaintiff,
`JANE DOE
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`UNITED STATES DISTRICT COURT
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`NORTHERN DISTRICT OF CALIFORNIA
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`JANE DOE,
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`Plaintiff,
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`vs.
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`APPLE INC. HEALTH AND WELFARE
`BENEFIT PLAN,
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`Defendant.
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`Case No.
`COMPLAINT FOR:
`BREACH OF THE EMPLOYEE
`RETIREMENT INCOME SECURITY
`ACT OF 1974; ENFORCEMENT AND
`CLARIFICATION OF RIGHTS;
`PREJUDGMENT AND
`POSTJUDGMENT INTEREST;
`PENALTIES; AND ATTORNEYS’ FEES
`AND COSTS
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`Plaintiff JANE DOE herein sets forth the allegations of her Complaint against Defendant
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`APPLE INC. HEALTH AND WELFARE BENEFIT PLAN.
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`PRELIMINARY ALLEGATIONS
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`1.
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`Jurisdiction: This action is brought under 29 U.S.C. §§ 1132(a), (e), (f) and (g) of the
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`Employee Retirement Income Security Act of 1974 (hereinafter “ERISA”) as it involves a claim by
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`Plaintiff for employee benefits under an employee benefit plan regulated and governed under ERISA.
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`Jurisdiction is predicated under these code sections as well as 28 U.S.C. § 1331 as this action
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`1
`COMPLAINT
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`(818) 886 2525
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`Northridge, California 91324
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`19839 Nordhoff Street
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`KANTOR & KANTOR LLP
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`

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`Case 5:22-cv-02566 Document 1 Filed 04/27/22 Page 2 of 7
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`involves a federal question. This action is brought for the purpose of obtaining benefits under the
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`terms of an employee benefit plan and enforcing Plaintiff’s rights under the terms of an employee
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`benefit plan. Plaintiff seeks relief, including but not limited to: payment of benefits, prejudgment and
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`post-judgment interest, and attorneys’ fees and costs.
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`2.
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`Plaintiff JANE DOE is a resident of San Jose, California and at all times relevant was
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`a resident in Santa Clara County, California. Therefore, venue is proper in this judicial district
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`pursuant to 29 U.S.C. § 1132(e)(2).
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`3.
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`4.
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`At the time of the events described below Plaintiff was a minor.
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`Furthermore, the evidence to be presented in this matter contains highly sensitive
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`personal information related to Plaintiff’s mental health. The evidence includes treatment notes and
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`other records documenting Plaintiff’s medical and personal history, and describes the nature of
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`Plaintiff’s complex and fragile mental health.
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`5.
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`For these reasons, and pursuant to Federal Rule of Civil Procedure 5.2, Plaintiff is
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`proceeding under a pseudonym.
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`6.
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`Plaintiff was at all relevant times a beneficiary under Defendant APPLE INC.
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`HEALTH AND WELFARE BENEFIT PLAN (the “Plan”), an employee group health benefit plan
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`pursuant to which Plaintiff was entitled to health benefits.
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`7.
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`The Plan has its principal place of business in Cupertino, California, is authorized to
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`transact and is transacting business in this judicial district, the Northern District of California, and
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`can be found in the Northern District of California.
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`21
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`FIRST CLAIM FOR RELIEF
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`FOR DENIAL OF PLAN BENEFITS UNDER ERISA
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`8.
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`Plaintiff incorporates by reference the foregoing paragraphs as though fully set forth
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`herein.
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`9.
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`On January 26, 2020, Plaintiff was involuntarily admitted on a psychiatric hold
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`following a suicide attempt.
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`2
`COMPLAINT
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`(818) 886 2525
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`Northridge, California 91324
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`19839 Nordhoff Street
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`KANTOR & KANTOR LLP
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`Case 5:22-cv-02566 Document 1 Filed 04/27/22 Page 3 of 7
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`10. While Plaintiff was hospitalized, her father began researching residential treatment
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`centers (“RTCs”) that would be appropriate to treat Plaintiff’s conditions after her course of
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`inpatient treatment was completed.
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`11.
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`On February 12, 2020, Plaintiff’s father asked the Plan’s claim administrator,
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`United Behavioral Health (“UBH”) for coverage information regarding Avalon Hills Adolescent
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`Treatment Facility (“Avalon Hills”). UBH told Plaintiff’s father that it was “unable to auth to that
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`facility.”
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`12.
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`On February 19, 2020, UBH informed Plaintiff’s father about three residential
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`treatment providers, none of which had the highly specialized treatment components that Avalon
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`Hills offered and were specifically needed to treat Plaintiff’s condition.
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`13.
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`Also on February 19, 2020, Avalon Hills called UBH regarding Plaintiff’s
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`coverage. UBH stated, “Inbound call from Facility regarding M[ental]H[ealth]…Calling
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`regarding: Authorization for RTC.… This diagnosis is in scope for QuickCert, except when
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`treatment is I[ntensive]O[out]P[atient]. Auth request did not qualify for Admin QuickCert process
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`due to 3 or more admits. Verified the following INN Providers: Avalon Hills Adolescent
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`Treatment Facility.”
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`14.
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`Later on February 19, 2020, another UBH representative documented the
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`following: “Unavailable facility: Authorization unavailable for RTC and PHP L[evel]O[f]C[are]
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`due to Service Component Not Consistent with LOC Guidelines; Clinical Denial – Send For Peer
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`Review; medical oversight[.]”
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`15.
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`Avalon Hills initially requested a peer-to-peer review of UBH’s decision. However,
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`upon realizing that UBH had denied the authorization of benefits on a non-clinical basis, Avalon
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`Hills rescinded its request for a peer-to-peer review, and requested a denial letter so that Plaintiff’s
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`family could appeal.
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`16.
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`Initially, UBH refused to provide a denial letter, claiming that Avalon Hills had
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`rescinded its request for coverage: “advised that since facility chose not to do the review but rather
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`rescinded their request a denial letter will not be issued or sent since we didn’t yet deny anything.”
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`COMPLAINT
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`(818) 886 2525
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`Northridge, California 91324
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`19839 Nordhoff Street
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`KANTOR & KANTOR LLP
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`Case 5:22-cv-02566 Document 1 Filed 04/27/22 Page 4 of 7
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`17.
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`On March 4, 2020, Avalon Hills called UBH and provided updated clinical
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`information in order for UBH to conduct a peer review.
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`18.
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`On March 6, 2020, UBH’s peer reviewer Dr. Joan Odom participated in a
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`telephonic peer-to-peer review with representatives from Avalon Hills.
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`19.
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`At the end of the review, Dr. Odom concluded that Plaintiff did indeed need
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`continued treatment at the residential level.
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`20.
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`However, Dr. Odom stated, “it is my determination that the requested service does
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`not meet the CASII Recommendations required to be followed in the member’s behavioral health
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`plan benefits. Specifically, authorization is unavailable for RTC and PHP LOCs at this facility due
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`to Service Components Not Consistent with LOC Guidelines.”
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`21.
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`On March 9, 2020, UBH issued a written denial letter written by Dr. Odom.
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`22.
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`In her letter, Dr. Odom stated, “it is my determination that no further authorization
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`can be provided from 03/04/2020 forward…the current facility does not have service components
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`that meet Optum’s requirements for CASII Level 5: Medically Monitored Residential Services.”
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`23.
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`In her letter, Dr. Odom did not offer an explanation as to how Avalon Hills did not
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`meet required “service components for residential treatment.”
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`24.
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`Plaintiff appealed this decision on September 3, 2020.
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`25.
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`UBH denied Plaintiff’s appeal in a letter dated October 2, 2020.
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`26.
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`The rationale for UBH’s denial in its October 2, 2020 letter was: “Optum practice
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`management had determined that Avalon Hills Adolescent Treatment Facility did not meet clinical
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`service guidelines for this level of care. The facility has been designated as not available for
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`authorization. Further questions regarding this status can be directed to Optum Practice
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`Management. Your treatment could’ve been provided at alternate residential programs that was
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`meeting our guidelines for CASII Service Level 5: Medically Monitored Residential Service
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`(residential treatment)…Please discuss your treatment with your provider.”
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`27.
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`Plaintiff submitted a second-level appeal of this decision on August 6, 2021.
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`28.
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`To date, UBH has not rendered a decision on Plaintiff’s second-level appeal, in
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`violation of ERISA claim regulations.
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`4
`COMPLAINT
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`(818) 886 2525
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`Northridge, California 91324
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`19839 Nordhoff Street
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`KANTOR & KANTOR LLP
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`

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`Case 5:22-cv-02566 Document 1 Filed 04/27/22 Page 5 of 7
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`29.
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`Because Defendant did not approve her claim for benefits, Plaintiff has incurred the
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`cost of her medical treatment at Avalon Hills.
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`30. Defendant wrongfully denied Plaintiff’s request for authorization and coverage of her
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`treatment at Avalon Hills in the following respects, among others:
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`(a)
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`Failure to authorize and pay for medical services rendered to Plaintiff as
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`required by the Plan at a time when Defendant and its claim administrators
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`knew Plaintiff was entitled to such benefits under the terms of the Plan;
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`(b)
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`Failure to provide reasonable explanations of the bases relied on under the
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`terms of the Plan, in relation to the applicable facts and plan provisions, for
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`the denial of Plaintiff’s request for authorization and coverage of her
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`treatment at Avalon Hills;
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`(c)
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`After Plaintiff’s requests were denied in whole or in part, failure to
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`adequately describe to Plaintiff any additional material or information
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`necessary to perfect her request along with an explanation of why such
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`material is or was necessary;
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`(d)
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`Failure to properly and adequately investigate the merits of Plaintiff’s
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`request; and
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`(e)
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`Failure to provide Plaintiff with a full and fair review pursuant to 29
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`C.F.R.§ 2560.503-1(g)-(j).
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`31.
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`Plaintiff is informed and believes and thereon alleges that Defendant wrongfully
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`denied Plaintiff’s claims for medical benefits by other acts or omissions of which Plaintiff is
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`presently unaware, but which may be discovered in this future litigation and of which Plaintiff will
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`immediately make Defendant aware once said acts or omissions are discovered by Plaintiff.
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`32.
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`Following the denial of the request under the Plan, Plaintiff exhausted all
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`administrative remedies required under ERISA, and performed all duties and obligations on her part
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`to be performed.
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`(818) 886 2525
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`Northridge, California 91324
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`19839 Nordhoff Street
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`KANTOR & KANTOR LLP
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`5
`COMPLAINT
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`33. As a proximate result of the denial of medical benefits due Plaintiff, Plaintiff has been
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`damaged in the amount of the cost incurred for her treatment, in a total sum to be proven at the time
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`of trial.
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`34. As a further direct and proximate result of this improper determination regarding the
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`medical claims, Plaintiff, in pursuing this action, has been required to incur attorneys’ costs and fees.
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`Pursuant to 29 U.S.C. § 1132(g)(1), Plaintiff is entitled to have such fees and costs paid by
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`Defendant.
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`35. Due to the wrongful conduct of Defendant, Plaintiff is entitled to enforce her rights
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`under the terms of the Plan and to clarify her right to benefits under the terms of the Plan.
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`SECOND CLAIM FOR RELIEF
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`FOR EQUITABLE RELIEF UNDER ERISA
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`36.
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`Plaintiff incorporates by reference the foregoing paragraphs as though fully set forth
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`herein.
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`37. As a direct and proximate result of the failure of Defendant to approve Plaintiff’s
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`request for authorization and coverage of her treatment at Avalon Hills, and the resulting injuries and
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`damages sustained by Plaintiff as alleged herein, Plaintiff is entitled to and hereby requests that this
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`Court grant Plaintiff the following relief pursuant to 29 U.S.C. § 1132(a)(1)(B):
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`(a)
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`Restitution of all past benefits due to Plaintiff, plus prejudgment and post-
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`judgment interest at the lawful rate; and
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`(b)
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`An order requiring Defendant to approve Plaintiff’s request for
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`authorization and coverage of her treatment at Avalon Hills;
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`(c)
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`Such other and further relief as the Court deems necessary and proper to
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`protect the interests of Plaintiff under the Plan.
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`COMPLAINT
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`(818) 886 2525
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`Northridge, California 91324
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`19839 Nordhoff Street
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`KANTOR & KANTOR LLP
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`Case 5:22-cv-02566 Document 1 Filed 04/27/22 Page 7 of 7
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`REQUEST FOR RELIEF
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`Wherefore, Plaintiff prays for judgment against Defendant as follows:
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`1.
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`Payment of health care benefits due to Plaintiff under the Plan;
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`2.
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`Pursuant to 29 U.S.C. § 1132(g), payment of all costs and attorneys’ fees incurred
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`in pursuing this action;
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`3.
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`Payment of prejudgment and post-judgment interest as allowed for under ERISA;
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`and
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`4.
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`For such other and further relief as the Court deems just and proper.
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`DATED: April 27, 2022
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`KANTOR & KANTOR, LLP
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`BY: /s/ Peter S. Sessions
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`Peter S. Sessions
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`Attorneys for Plaintiff,
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`JANE DOE
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`7
`COMPLAINT
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`(818) 886 2525
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`Northridge, California 91324
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`19839 Nordhoff Street
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`KANTOR & KANTOR LLP
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