Case 1:20-cv-00164-TS Document 2 Filed 11/25/20 PageID.2 Page 1 of 22
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`Brian S. King, #4610
`Brent J. Newton, #6950
`Samuel M. Hall, #16066
`BRIAN S. KING, P.C.
`420 East South Temple, Suite 420
`Salt Lake City, UT 84111
`Telephone: (801) 532-1739
`Facsimile: (801) 532-1936
`brian@briansking.com
`brent@briansking.com
`samuel@briansking.com
`
`Attorneys for Plaintiffs
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`THE UNITED STATES DISTRICT COURT
`DISTRICT OF UTAH, CENTRAL DIVISION
`
`ANNEMARIE O. individually and on behalf
`of A. P. a minor,
`
`COMPLAINT
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`Case No. 1:20-cv-00164 TS
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`Plaintiffs,
`
`vs.
`
`UNITED HEALTHCARE INSURANCE
`COMPANY, CIGNA HEALTH and LIFE
`INSURANCE COMPANY, and the UTC
`CHOICE MEDICAL PLAN,
`
`Defendants.
`
`Plaintiff Annemarie O. (“Annemarie”), individually and on behalf of A. P. (“A.”) a
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`minor, through her undersigned counsel, complains and alleges against Defendants United
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`Healthcare Insurance Company (“United”), Cigna Health and Life Insurance Company,
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`(“Cigna”) and the UTC Choice Medical Plan (“the Plan”) as follows:
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`PARTIES, JURISDICTION AND VENUE
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`1. Annemarie is a natural person residing in Dallas County, Texas and New Haven County
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`Connecticut respectively. Annemarie is A.’s mother.
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`2. United is an insurance company headquartered in Hennepin County, Minnesota and was
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`the insurer and claims administrator for the Plan during the treatment at issue in this case
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`during the year 2017. During the year 2018, Cigna became primary insurer for the Plan
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`and United assumed the role of secondary insurer.
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`3. The UTC Choice Medical Plan (“the Plan”) is a employee welfare benefits plan
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`established to provide health benefits for employees of United Technologies and their
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`dependents.
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`4. In 2017 the Plan was fully insured through United. In 2018 the Plan was self-funded and
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`was administered by Cigna. At all times the Plan was subject to 29 U.S.C. §1001 et. seq.,
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`the Employee Retirement Income Security Act of 1974 (“ERISA”). Annemarie was and
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`remains a participant in the Plan and A. is a beneficiary of the Plan.
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`5. A. received medical care and treatment at ViewPoint Center (“ViewPoint”) from October
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`27, 2017, to December 10, 2017, and Change Academy Lake of the Ozarks (“CALO”)
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`from December 11, 2017, to May 20, 2019 These are residential treatment facilities,
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`which provide sub-acute inpatient treatment to adolescents with mental health,
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`behavioral, and/or substance abuse problems. ViewPoint is located in Utah and CALO is
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`located in Missouri.
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`6. United, acting in its own capacity or through its subsidiary and affiliate United
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`Behavioral Health or under the brand name Optum, denied claims for payment of A.’s
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`medical expenses in connection with her treatment at ViewPoint and CALO. This lawsuit
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`is brought to obtain the Court’s order requiring United and the Plan to reimburse
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`Annemarie for the medical expenses she has incurred and paid for A.’s treatment during
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`the period for which it was responsible under the Plan.
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`7. Cigna similarly denied payment for A.’s medical expenses at CALO, either in its own
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`capacity or through its subsidiary and affiliate Cigna Behavioral Health. This lawsuit also
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`seeks reimbursement from Cigna and the Plan for A.’s medically necessary treatment at
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`CALO during the period that Cigna was responsible for A.’s treatment.
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`8. This Court has jurisdiction over this case under 29 U.S.C. §1132(e)(1) and 28 U.S.C.
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`§1331.
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`9. Venue is appropriate under 29 U.S.C. §1132(e)(2) and 28 U.S.C. §1391(c) based on
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`ERISA’s nationwide service of process and venue provisions, because the Defendants do
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`business in Utah, and a critical portion of the treatment at issue took place in Utah.
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`Finally, in light of the sensitive nature of the medical treatment at issue, it is the
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`Plaintiffs’ desire that the case be resolved in the State of Utah where it is more likely
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`their privacy will be preserved.
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`10. The remedies the Plaintiffs seek under the terms of ERISA and under the Plan are for the
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`benefits due under the terms of the Plan, and pursuant to 29 U.S.C. §1132(a)(1)(B), for
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`appropriate equitable relief under 29 U.S.C. §1132(a)(3) based on the Defendants’
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`violation of the Mental Health Parity and Addiction Equity Act of 2008 ("MHPAEA"),
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`an award of prejudgment interest, and an award of attorney fees and costs pursuant to 29
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`U.S.C. §1132(g).
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`BACKGROUND FACTS
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`11. A. was born in Russia and suffered from a series of medical issues in her early life, such
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`as a rare genetic heart condition which required her to undergo heart surgery at the age of
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`six months. A.’s medical problems led to her biological parents placing her in a Russian
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`orphanage. A. was subsequently adopted by the Plaintiffs and moved to the United States,
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`but she exhibited severe behavioral problems such as attachment issues and anxiety,
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`which got worse as she grew older.
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`12. A. frequently engaged in attention seeking behaviors. She would lie compulsively
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`(including alleging false claims of abuse which she later recanted), had difficulty with
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`self-regulation, had difficulty making or keeping friends, rarely expressed remorse for her
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`actions, and had frequent intense outbursts.
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`13. A. underwent psychological testing and was found to have low self-regulation and
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`impulse control skills. She was found to employ maladaptive coping skills such as
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`hypervigilance, emotional outbursts, and threatening behaviors, all of which were greatly
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`exacerbated due to transitions or stressful situations and led to her becoming easily
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`overwhelmed. A. also exhibited hypersexualized behavior including with her 12 year old
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`stepbrother.
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`United
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`14. A. was admitted to ViewPoint on October 27, 2017, with United’s approval.
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`15. In a letter dated November 29, 2017, United denied payment for A.’s treatment from
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`November 28, 2017, forward. The letter offered the following justification for the denial.
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`…Your child was admitted for treatment of Depression, Anxiety and Behavioral
`Problems. After talking with your child’s provider, it is noted your child has made
`progress and that your child’s condition no longer meets Guidelines for further
`coverage of treatment in this setting. Your child’s symptoms have improved.
`Your child is not aggressive. Your child is not currently at risk of harm to self or
`others. Your child is making progress in treatment. Your child is able to
`participate in treatment. Your child does not require 24-hour nursing care. Your
`child could continue care in the Mental Health Outpatient setting. …
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`16. On February 14, 2018, ViewPoint appealed the denial on the Plaintiffs’ behalf.
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`ViewPoint included a copy of A.’s medical records with the appeal and argued that these
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`records showed that A.’s treatment at ViewPoint was medically necessary to adequately
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`treat her diagnoses of Reactive Attachment Disorder, anxiety, and Attention-deficit
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`Hyperactivity Disorder.
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`17. ViewPoint contended that it was not clear from United’s denial letter why it had suddenly
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`deemed A.’s treatment to no longer be medically necessary. ViewPoint noted that United
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`had denied treatment due to a sudden requirement of “immaterial acute deteriorations in
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`her condition.” ViewPoint noted that A. was not treated for acute symptoms while she
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`received treatment there.
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`18. In a letter dated April 20, 2018, United upheld the denial of payment for A.’s treatment.
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`The letter stated in part:
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`Your daughter’s symptoms had stabilized. 24 hour monitoring in a supervised
`setting was no longer required to avoid risk of harm to self or others. She was not
`engaging in disruptive behaviors or self-injurious behaviors. There were no noted
`acute psychosocial and environmental problems that were likely to threaten her
`safety. She had no co-occurring medical or substance abuse complications that
`would need 24-hour care. She presented no acute behavioral management
`challenges. She was generally cooperative, responsive to staff, and doing better.
`She required no medication. She was eating, sleeping and independently doing
`her daily activities. She was engaged in therapeutic programming and developing
`coping skills. Some insight was developing. She was attending school, groups and
`therapies. Her care could have continued in a (non-24 hour) Intensive Outpatient
`setting, preferably near home, with individual therapy, family work along with
`standard school adjustments. This would have helped to monitor and maintain her
`stability, continue to increase her functioning, develop a support system and
`further strengthen key relationships with friends and treatment professionals,
`while integrating her back into family and community life.
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`19. On May 21, 2018, A.’s father, Duane, submitted a level one appeal of the denial of
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`payment for A.’s treatment at ViewPoint. He noted that while A. had made some
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`progress while she was at ViewPoint, at the time that United elected to deny care, she had
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`not yet progressed enough for her to be safely discharged from the program.
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`20. Duane reminded United of its responsibilities under ERISA and urged it to comply with
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`the statute in future reviews; he argued that United had fallen short of ERISA’s
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`requirements in numerous respects and that he had not been provided with a full and fair
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`review.
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`21. contended that A.’s treatment was medically necessary and that her medical records
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`proved this.
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`22. These records showed that A. struggled with an emerging eating disorder, deceitful
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`behavior, avoidance, unhealthy attachments, difficulty regulating emotions, and a lack of
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`insight and remorse. Duane wrote that outpatient treatment had thus far been ineffective,
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`and pointed out that United agreed with this assessment as it initially approved A.’s
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`treatment. He contended that if A. were to have returned home before completing her
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`treatment then her behaviors would have likely regressed significantly, especially given
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`the fact that she required additional treatment following her discharge from ViewPoint.
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`23. He pointed out that MHPAEA required insurers to provide coverage for mental health
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`services “at parity with equivalent medical and surgical services.” He identified skilled
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`nursing and inpatient rehabilitation as some of the medical or surgical analogues to
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`residential treatment.
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`24. He contended that while United imposed acute care requirements on A.’s residential
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`treatment, it did not do so for comparable medical or surgical services, he alleged that
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`this constituted an impermissible treatment limitation in violation of MHPAEA. Duane
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`directed United to perform a full parity analysis of the Plan to ensure MHPAEA
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`compliance. He noted that it would be inappropriate to treat individuals suffering from
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`acute symptomology in a non-acute environment.
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`25. Duane took issue with the denial rationales that United employed to deny A.’s treatment.
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`He noted that not only did it use acute criteria for a sub-acute level of care, but United
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`also denied care for reasons such as “Your child is making progress in treatment” and
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`“Your child’s symptoms have improved.” He contended that these were not valid
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`justifications to deny care, and that just because A. had made some progress, it did not
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`mean that her treatment was complete.
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`26. He requested that in the event that the denial was upheld that United provide him with a
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`copy of all documents under which the Plan was operated, including all governing plan
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`documents, the summary plan description, any insurance policies in place for the benefits
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`he was seeking, any administrative service agreements that existed, the Plan’s mental
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`health and substance abuse criteria, the Plan’s criteria for skilled nursing and
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`rehabilitation facilities, and any reports from any physician or other professional
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`concerning the claim (collectively the “Plan Documents”).
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`27. In a letter dated July 13, 2018, United upheld the denial of payment for A.’s treatment at
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`ViewPoint. The reviewer wrote in part:
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`…Based on the Optum Level of Care Guideline for the Mental Health Residential
`Treatment Center Level of Care, it is my determination that that [sic] no further
`authorization can be provided from November 28, 2017.
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`Your child was admitted for treatment of problems with her behavior, mood, and
`eating. After reviewing the available information, it is noted your child had made
`progress and that your child’s condition no longer met Guidelines for further
`coverage of treatment in this setting. She was doing better. She was stable from a
`medical and mental health standpoint. She was not taking any medicine. She was
`participating in treatment. She was using the skills she was learning. She had
`family support. She did not require 24-hour nursing care. Your child could have
`continued care in the Mental Health Intensive Outpatient Program setting. …
`
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`CALO
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`28. A. was admitted to CALO on December 11, 2017.
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`29. In a letter addressed to CALO dated October 10, 2018, United denied payment for A.’s
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`treatment at CALO. The letter only addressed dates in the month of December of 2017.
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`The letter stated in part:
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`[A.] was no longer in any serious or severe risk of self-harm. There were no
`medical comorbidities that require nursing care. Her psychiatric condition was
`stable. There was no psychosis, no suicidal ideation, no self-harm, no threats to
`others, no aggressive or bizarre behavior, and her behavior was under good
`control. She appeared to be engaged and participating in groups and activities
`without the need for strict supervision and monitoring. She was not at risk for
`imminent acting out.
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`In addition, her providers were not independently licensed. Services that are
`provided by clinicians who are not independently licensed are not a covered
`benefit under this policy. …
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`30. On October 17, 2018, Duane submitted a level one appeal request for the denial of A.’s
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`treatment at CALO. As the October 10, 2018, denial letter referenced above was sent to
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`CALO and not to Duane, he relied on an Explanation of Benefits (“EOB”) statement
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`dated September 7, 2018, as a basis to draft his appeal. The justification given by United
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`in its EOB for denying payment was different from what it told CALO. The EOB stated
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`in part:
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`Your plan provides benefits for services that are determined to be covered health
`services. The information received does not support measurable progress toward
`defined treatment goals for these services. Therefore, additional benefits are not
`available.
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`31. Duane reminded United of its responsibilities under ERISA, such as its obligation to act
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`in his best interest and to provide him with a full, fair, and thorough review. Duane stated
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`that contrary to its assertion in its EOB, United had all of the information that it needed to
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`evaluate the claim. Nevertheless, he included his contact information with the appeal and
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`encouraged United to reach out if it needed any more information.
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`32. He argued that the treatment was medically necessary and that CALO specialized in
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`treating individuals like A. who suffered from Reactive Attachment Disorder. He wrote
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`that Reactive Attachment Disorder was a highly specialized diagnosis which required a
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`very specific type of treatment. He stated that A. would transition to outpatient therapy as
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`soon as her treatment team judged that it was safe for her to do so.
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`33. Duane expressed concern that United partially denied A.’s treatment due to a lack of
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`“measurable progress.” He argued that this constituted a nonquantitative treatment
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`limitation in violation of MHPAEA.
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`34. He wrote that MHPAEA required insurers to offer mental health coverage “at parity”
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`with comparable levels of medical or surgical care. He identified skilled nursing and
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`inpatient rehabilitation facilities as analogues to A.’s residential treatment. He noted that
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`United did not impose treatment limitations such as a requirement of measurable progress
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`in order to approve treatment at these facilities.
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`35. Duane again requested to be provided with a copy of the Plan Documents.
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`36. On November 28, 2018, Duane submitted another appeal after he was provided with the
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`October 10, 2018, denial letter addressed to CALO. Duane protested that United
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`continued to evaluate A.’s subacute level of care using acute level criteria. He contended
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`that using criteria such as a “serious or severe risk of self-harm” was inappropriate for the
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`sub-acute level of care A. was receiving, and was “incongruent with sound medical
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`judgement.” Duane questioned how he could trust that United was acting in good faith
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`when it failed to meet all of its obligations.
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`37. He wrote that CALO was a licensed and accredited residential treatment center, and that
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`CALO also met the Plan’s definition of a residential treatment facility. He reiterated that
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`United’s denial violated MHPAEA as the Plan’s requirements for coverage in a skilled
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`nursing facility were “far less strict than the requirement for residential treatment
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`facilities.” He again requested to be provided with a copy of the Plan Documents.
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`38. In a letter dated December 12, 2018, addressed to CALO. United stated that it had
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`received an appeal but would not process it as all available grievance/appeal options had
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`been exhausted.
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`39. On February 7, 2019, Duane submitted a complaint to the Plan administrator regarding
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`United’s mishandling of his appeals. Duane wrote that his member appeal had mistakenly
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`been processed as a provider appeal. He wrote that despite his attempts to rectify the
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`problem, including numerous calls to United, it had failed to correct the error. He
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`expressed concern that the deadline for him to file a level two appeal was rapidly
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`approaching but he had still not received a proper response to his appeal.
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`40. He stated that he was forced to file a second appeal for dates of service January 1, 2018,
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`forward but United also failed to respond to this appeal despite its obligation to do so
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`within 30 days and despite multiple attempts on his part at following up with United. He
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`wrote that at one point, United’s representatives misinformed him that his appeal rights
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`had been exhausted when they had not been.
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`41. Duane wrote, “To date, I have yet to receive an accurate response to any of my member
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`appeals.” Duane contended that this left him unable to fully appeal the denials and that as
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`United had not even processed some dates of service, it left him unable to know whether
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`United had an adverse or favorable determination for a portion of A.’s treatment. He
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`argued that this was a breach of the terms of the Plan, and that although he had upheld his
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`obligations, United had not upheld its obligations.
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`42. In a document titled “CORRECTED LETTER” dated March 4, 2019, United upheld the
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`denial “on a request we received 09/19/2018” The letter is strikingly similar to United’s
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`initial October 10, 2018, denial. Although the letter had been partially rewritten, it is
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`largely unchanged from the original and quotes the October 10, 2018 denial in paragraph
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`27 word for word. Both letters are signed by Associate Medical Director, Dr. Thomas
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`Blocher.1
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`Cigna
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`43. In a letter dated March 29, 2018, Cigna denied payment for A.’s treatment at CALO. The
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`reviewer stated in part:
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`The clinical basis for this decision is: Based upon the available clinical
`information, your symptoms did not meet Cigna’s Behavioral Health Medical
`Necessity Criteria for admission and continued stay at the Residential Mental
`Health Treatment for Children and Adolescents level of care from 01/01/2018 -
`08/31/2018 as the information provided described you as being able to understand
`information presented to you and being in behavioral control. There was no report
`of any physical instability or psychosis driving your behaviors. There was no
`evidence of threat to anybody. As there was nothing proposed requiring around-
`the-clock structure and interventions, there was nothing suggesting that you
`would not be able to successfully and safely use structured outpatient services to
`continue working on your mental health issues and mastery of healthy coping
`skills and for medication management rather than an extended stay in an around-
`the-clock setting.
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`44. In a letter dated August 8, 2018, addressed to A. but written in response to a CALO
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`provider appeal, Cigna upheld the denial of payment for A.’s treatment at CALO. The
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`reviewer gave the following justification for the denial:
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`Based upon the available clinical information received initially and for this
`appeal, your symptoms did not meet Cigna Behavioral Health Medical Necessity
`Criteria for continued stay at Child/Adolescent Mental Health Residential
`Treatment level of care from 01/01/2018 – 08/31/2018. There was no current risk
`
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`1 While some of the surrounding text has been changed between the two letters, the denial rationale is identical. It is
`unclear why United, having failed to respond to Duane’s previous appeals, opted to send him a letter which recycled
`the language and analysis which Dr. Blocher wrote to a provider months earlier, instead of drafting a new letter
`which attempted to address the arguments Duane raised in the appeal process.
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`of harm to yourself or others. You did not demonstrate a need for 24-hour/day
`monitoring and active treatment. Your family was involved in treatment. From the
`available clinical evidence, you could have received psychiatric treatment in a less
`restrictive setting. Appropriate lower levels of care were available for further
`stabilization. Therefore, the initial determination is upheld.
`
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`45. On September 21, 2018, Duane and Annemarie submitted a level one appeal of the denial
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`of A.’s treatment at CALO. They contended that A.’s treatment was medically necessary
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`and that Cigna utilized acute inpatient criteria to evaluate A.’s sub-acute treatment and
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`that this was “unfair and inappropriate.”
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`46. They contended that A.’s treatment satisfied the Plan’s definition of medical necessity
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`and was required to treat her chronic behavioral health conditions, consistent with
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`generally accepted standards of medical practice, and was “rendered in the least
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`restrictive setting that could still provide safe and effective treatment.”
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`47. They described the difficulties in treating individuals like A. who suffered from Reactive
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`Attachment Disorder, and argued that “the multidisciplinary therapeutic approach only
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`available in a long-term residential treatment center like CALO is uniquely able to
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`provide safe and effective treatment for patients like [A.]…” They again requested to be
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`provided with a copy of the Plan Documents.
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`48. In a letter dated December 10, 2018, Cigna upheld the denial of payment for A.’s
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`treatment at CALO. The letter stated in part:
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`…The clinical basis for this decision is: Based upon the available clinical
`information, your symptoms did not meet Cigna Behavioral Health Medical
`Necessity Criteria for continued stay at Residential Mental Health Treatment for
`Children and Adolescents level of care from 08/31/2018 – 03/31/2019 as
`insufficient clinical information has been provided by the facility to support the
`medical necessity for this requested level of care. Sufficient updated information
`such as ongoing process documentation has not been provided to explain why the
`current treatment could not have occurred at a less restrictive level of care.
`Therefore, this request is denied. …
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`49. Cigna sent another letter also dated December 10, 2018, with a separate justification for
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`the denial. It stated in part:
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`Based upon the available clinical information received initially and for this
`appeal, your symptoms did not meet Cigna Behavioral Health Medical Necessity
`Criteria for admission and continued stay at Residential Mental Health Treatment
`for Children and Adolescents level of care from 01/01/2018 – 03/31/2019. There
`was no current risk of harm to yourself or others. You did not demonstrate a need
`for 24 hour/day monitoring and active treatment. Your family was involved in
`treatment. From the available clinical evidence, you could have received
`psychiatric treatment in a less restrictive setting. Appropriate lower levels of care
`were available for further stabilization. Therefore, the initial determination is
`upheld.
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`50. On January 21, 2019, Duane and Annemarie submitted a level two appeal of the denial of
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`A.’s treatment at CALO.2 They argued that A.’s treatment continued to be medically
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`necessary given her ongoing Reactive Attachment Disorder and high risk behaviors.
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`51. They expressed concern that they had not been given the full, fair, and thorough review
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`to which they were entitled. They noted that they had been sent multiple denial letters by
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`Cigna with nearly identical verbiage. They questioned how Cigna could adequately
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`address the arguments raised in separate appeals by copy and pasting generic denial
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`rationales with identical wording. They contended that this was an arbitrary practice done
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`to avoid having to pay for medically necessary treatment.
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`52. They noted that while Cigna’s December 10, 2018, letter stated that its denial “represents
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`the final step of the internal appeal process” this contradicted the express terms of the
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`Plan which stated that “If you are dissatisfied with the Claims Administrator’s level one
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`appeal decision, you may request a second review…” They requested that they be given a
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`second level internal appeal as was their right under the terms of the Plan.
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`2 This appeal states that it is written in response to the denial letter in paragraph 47 directly above. It does not make
`mention of Cigna’s other December 10, 2018, denial letter.
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`53. They included an updated copy of A.’s medical records with the appeal and argued that
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`A.’s treatment at CALO was necessary to properly treat her maladaptive behaviors. They
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`took issue with Cigna’s use of acute criteria to evaluate a sub-acute level of mental health
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`care. They noted that these acute requirements were absent from Cigna’s general criteria
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`for a residential level of care. They wrote that residential treatment centers offered a sub-
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`acute level of care and were not equipped to treat acute symptoms and that expecting
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`them to do so constituted a non-quantitative treatment limitation and was far outside the
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`realm of generally accepted standards of medical practice.
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`54. They argued that A.’s treatment was consistent with the Plan’s definition of medical
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`necessity and that less restrictive levels of care had been attempted but had not been
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`shown to be effective and that A. needed specialized treatment, especially given her
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`diagnosis of Reactive Attachment Disorder. They again requested to be provided with a
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`copy of the Plan Documents.
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`55. In spite of Duane and Annemarie’s assertion that their internal appeal rights were not
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`exhausted and their request for their appeal to be evaluated by Cigna, Cigna outsourced
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`review of the claim to an external agency. In a letter dated June 4, 2019. MLS National
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`Medical Evaluation Services upheld the denial of payment for A.’s treatment at CALO.
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`The unidentified reviewer wrote in part:
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`In this case there was no report of any physical instability or psychosis driving the
`member’s behaviors. She was not suicidal or homicidal and did not pose a threat.
`The member was also not requiring 24 hour round the clock care based on her
`level of severity.
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`The member could be managed at a lower level of care along with preventative
`measures that could be implemented also by the family. This could be home
`behavioral analysis to work with the parents providing a reinforcement schedule
`high risk behaviors [sic] for minors trying to engage in sexual online activity. An
`outpatient level of care such as partial hospital program [sic] or intensive
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`14
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`Case 1:20-cv-00164-TS Document 2 Filed 11/25/20 PageID.16 Page 15 of 22
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`outpatient program would be beneficial in this case. This will include a multi
`system approach including active family therapy and individual trauma therapy
`working with the collaboration clinical team of providers.
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`56. On July 16, 2019, Duane and Anne-Marie wrote a response letter to the external
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`reviewer’s adverse determination. They noted that the external reviewer had not
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`evaluated all of the dates of service as they had requested, which deprived them of appeal
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`rights for certain dates of service.
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`57. They protested that their level two appeal had been processed as an external review
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`request in spite of their explicit direction to the contrary. They contended that whether
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`this oversight by Cigna was malicious or simply a mistake, it had the end result of
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`depriving them of a second level appeal and resulted in an uncontestable adverse
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`determination before they had properly exhausted their appeal rights.
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`58. The Plaintiffs exhausted their pre-litigation appeal obligations – to the extent to which
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`they were able given the procedural irregularities in the manner which the Defendants
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`handled the appeals process– under the terms of the Plan and ERISA.
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`59. The denial of benefits for A.’s treatment was a breach of contract and caused Duane and
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`Annemarie to incur medical expenses that should have been paid by the Plan in an
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`amount totaling over $300,000.
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`60. The Defendants failed to produce a copy of the Plan Documents, including any medical
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`necessity criteria for mental health and substance use disorder treatment and for skilled
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`nursing or rehabilitation facilities in spite of the Plaintiffs’ requests.
`
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`15
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`Case 1:20-cv-00164-TS Document 2 Filed 11/25/20 PageID.17 Page 16 of 22
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`FIRST CAUSE OF ACTION
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`(Claim for Recovery of Benefits Under 29 U.S.C. §1132(a)(1)(B))
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`61. ERISA imposes higher-than-marketplace quality standards on insurers and plan
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`administrators. It sets forth a special standard of care upon plan fiduciaries such as United
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`and Cigna, acting as agents of the Plan, to “discharge [their] duties in respect to claims
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`processing solely in the interests of the participants and beneficiaries” of the Plan. 29
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`U.S.C. §1104(a)(1).
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`62. ERISA also underscores the particular importance of accurate claims processing and
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`evaluation by requiring that administrators provide a “full and fair review” of claim
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`denials and to engage in a meaningful dialogue with the Plaintiffs in the pre-litigation
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`appeal process. 29 U.S.C. §1133(2).
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`63. The denial letters produced by the Defendants do little to elucidate whether they
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`conducted a meaningful analysis of the Plaintiffs’ appeals or whether they provided the
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`Plaintiffs with the “full and fair review” to which they are entitled. The Defendants’
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`denial letters contain similar, often word-for-word identical language, and do not
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`substantively address the arguments raised during the appeal process.
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`64. In addition, the denial rationales offered by the Defendants are not consistent. Oftentimes
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`the Defendants sent letters to the residential treatment facilities A. attended which gave
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`different justifications for denying care than the explanations which were given to the
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`Plaintiffs. For instance, Cigna sent two letters, one to CALO and one to the Plaintiffs,
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`each dated December 10, 2018, each s