Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.2 Page 1 of 18
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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
`tera@briansking.com
`
`Attorneys for Plaintiffs
`
`THE UNITED STATES DISTRICT COURT
`DISTRICT OF UTAH, CENTRAL DIVISION
`
`A.H., and K.H.,
`
`COMPLAINT
`
`Plaintiffs,
`
`vs.
`
`Case No. 1:22-cv-00081 - DBP
`
`UNITED HEALTHCARE INSURANCE
`COMPANY, UNITED BEHAVIORAL
`HEALTH, and the DELTA PILOTS
`MEDICAL PLAN (DPMP) INCLUDING A
`NETWORK OPTION AND OUT-OF-AREA
`(OOA) OPTION
`
`Defendants.
`
`Plaintiffs A.H. and K.H. (“K.H.”), through their undersigned counsel, complain and
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`allege against Defendants, United Healthcare Insurance Company (“UHC”), United Behavioral
`
`Health (“UBH”) (collectively “United”) and the Delta Pilots Medical Plan (DPMP) Including a
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`Network Option and Out-of-Area (OOA) Option (“the Plan”) (collectively “Defendants”) as
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`follows:
`
`//
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`1
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.3 Page 2 of 18
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`PARTIES, JURISDICTION AND VENUE
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`1. A.H. and K.H. are natural persons residing in Pinellas County, Florida. A.H. is K.H.’s
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`father.
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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, as well as the fiduciary under ERISA for the Plan
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`during the treatment at issue in this case.
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`3. The Plan is a self-funded employee welfare benefits plan under 29 U.S.C. §1001 et. seq.,
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`the Employee Retirement Income Security Act of 1974 (“ERISA”). A.H. was a
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`participant in the Plan and K.H. was a beneficiary of the Plan at all relevant times. A.H.
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`and K.H. continue to be participants and beneficiaries of the Plan.
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`4. K.H. received medical care and treatment at Uinta Academy (“Uinta”) from October 22,
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`2019, to December 27, 2020. Uinta is a licensed treatment facility located in Cache
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`County, Utah, which provides sub-acute inpatient treatment to adolescents with mental
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`health, behavioral, and/or substance abuse problems.
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`5. UHC, acting in its own capacity or through its subsidiary and affiliate United Behavioral
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`Health (“UBH”), denied claims for payment of K.H.’s medical expenses in connection
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`with her treatment at Uinta.
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`6. 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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`7. 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 United does
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`business in Utah, has a claims processing facility in Salt Lake City where the appeals in
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`this case were sent, and the Plan has many participants and beneficiaries living in Utah.
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.4 Page 3 of 18
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`8. In addition, A.H. has been informed and reasonably believes that litigating the case
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`outside Utah will likely lead to substantially increased litigation costs for which he will
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`be responsible to pay, which would not be incurred if venue of the case remains 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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`9. 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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`K.H.’s Developmental History and Medical Background
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`10. K.H. was born by emergency cesarian section due to a dangerous pregnancy and induced
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`hypertension, leading to pre-eclampsia.
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`11. K.H. swallowed fluid upon delivery and spent several days in the NICU.
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`12. K.H. would cry inconsolably for hours every day as an infant and suffered from acute
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`acid reflux.
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`13. K.H. developed quickly, despite her pre-mature birth. She had to sleep in a toddler bed
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`before her first birthday because she could already remove herself from her crib and it
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`was unsafe.
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`14. As a child, K.H. was high energy, imaginative, outgoing, and strong willed.
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.5 Page 4 of 18
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`15. K.H. seemed unaware of how her peers would perceive her and was very bossy as a
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`child. She had bouts of defiance against teachers and was sometimes aggressive with
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`other children if she did not get her way.
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`16. K.H. was diagnosed with ADHD and Oppositional Defiant Disorder at the age of five.
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`17. K.H.’s parents brought her to a play therapist and eventually tried medication to help K.
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`with her mental health diagnosis.
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`18. K.H. did not react well to her medications. At best, some medications would work for a
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`short period of time and then become ineffective.
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`19. As K.H. grew older, her teachers would constantly reprimand her for not following the
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`rules and K.H. started to lose her self-esteem at a young age.
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`20. K. could work well with a younger friend who she would lead, or with an older friend
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`who she could follow, but K.H. had a hard time making friends with her peers as she did
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`not handle undefined roles well.
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`21. By the time K.H. was seven, her parents moved her from Dallas to Houston so that she
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`could be closer to her biological father’s family. Being close to this extended family gave
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`K.H. the increased structure and support that she needed.
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`22. A few weeks after K.H.’s tenth birthday, K.H.’s biological father died in a car accident
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`while on a work trip.
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`23. K.H. and her mother entered a grief program and K.H. started to see a private grief
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`counselor bi-weekly.
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`24. K.H.’s mother had to start working after the loss of K.H.’s biological father which led to
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`K.H,’s mother needing to hire a nanny due to the increased work travel.
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`4
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.6 Page 5 of 18
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`25. K.H. and her mother found a nanny who worked well, and after some time, that nanny
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`quit unexpectedly.
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`26. About this same time, K.H.’s grandparents stopped returning K.H.’s calls and they
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`phased K.H. out of their lives.
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`27. When K.H. was twelve, K.H.’s mother met A.H. and they eventually moved to Florida
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`and got married. K.H. asked A.H. to adopt her, and K.H. was excited to have a sister and
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`a new father figure.
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`28. A.H.’s ex-wife phased A.H.’s daughter out of K.H.’s life and K.H. quickly lost the sister
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`she was excited to have.
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`29. Between the ages of ten and twelve, K.H.’s grades started to slip dramatically, and she
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`started showing signs of depression.
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`30. K.H.’s parents started to find indications of self-harm such as cut marks on her arms and
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`legs around this time.
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`31. K.H. started to steal from her friends and family and would seem overly remorseful after
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`she was caught.
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`32. In 2016 and 2017, K.H.’s parents had her reevaluated and K.H. was then diagnosed with
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`Attention Deficit Hyperactivity Disorder – Combined Type, Disruptive Mood
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`Dysregulation Disorder, Unspecified Depressive Disorder, and Oppositional Defiant
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`Disorder.
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`33. K.H.’s parents worked with the school district to get a 504 plan in place but eventually, it
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`became evident that K.H. needed a more structured environment.
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`34. K.H.’s parents enrolled her into the Admiral Farragut Academy and they all moved
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`across the state to be with K.H. in this new school.
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.7 Page 6 of 18
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`35. K.H.’s impulsive behaviors caused her to get in trouble often at her new school and she
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`was heavily bullied for the next year and a half.
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`36. During this time, K.H. started expressing suicidal ideation, succumbed to urges of self-
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`harm and dealt with disordered eating. K.H. also started to engage in promiscuous
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`behaviors with boys to try and seek approval.
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`37. During these years, K.H. continued to see therapists and psychologists to try and help
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`manage her mental health conditions.
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`38. In 2018, an old friend came to stay with K.H. and her parents. K.H. confided in her
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`mother that the friend’s son was sexually inappropriate with her when they were between
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`five and ten years old, on several occasions.
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`39. In June of 2019, K.H. was admitted to an intensive outpatient therapy program which she
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`attended daily. At this program, she convinced the treating providers that her only issue
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`was an eating disorder and a week before she was discharged, they changed her
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`medications.
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`40. After K.H. was discharged from the intensive outpatient therapy program, she sunk into a
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`deep depression and was caught doing drugs, sneaking boys into the house, and cutting
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`her arms significantly.
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`41. K.H. cut her arms so badly one day that her mother had to take her to the hospital. K.H.
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`was voluntarily admitted into an intensive inpatient hospital program for five days.
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`42. After she was discharged from her inpatient program, she was referred to La Amistad, a
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`residential treatment center.
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`43. While K.H. was at La Amistad, she had admitted that she was taking drugs daily, she had
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`been raped, she was being abused, and she had no control over her life.
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`6
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.8 Page 7 of 18
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`44. While K.H. was at La Amistad, a family friend and her grandmother passed away.
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`45. When K.H. was discharged from La Amistad, she was diagnosed with Borderline
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`Personality Disorder, Post Traumatic Stress Disorder, Generalized Anxiety Disorder,
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`Social Anxiety Disorder, Anorexia Nervosa, and various Substance Abuse Disorders.
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`46. K.H.’s parents found Uinta to be a good fit for K.H. as they were able to handle all of
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`K.H.’s diagnoses while also helping her finish high school, despite her already turning
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`eighteen years old.
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`47. K.H. was admitted to Uinta on October 22, 2019.
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`Uinta
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`48. In a letter dated October 30, 2019, UBH denied K.H.’s treatment at Uinta stating in part,
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`[UBH] is responsible for making benefit coverage determinations for mental
`health and substance use disorder services that are provided to UBH members.
`…
`I have reviewed your treatment plan that was submitted by Unita [sic] Academy,
`and I have determined that coverage is not available under your benefit plan for
`the requested services of Residential.
`You were admitted at a mental health residential treatment program. This review
`is for a request for benefit coverage for this treatment effective 10/22/2019 and
`thereafter.
`After talking with your provider, it is noted that the facility/program is utilizing an
`unproven/experimental treatment modality, which is excluded and not a covered
`benefit per your benefit plan document and Optum review of this care.
`You cannot be covered for services or treatments that are unproven or
`experimental, as these are non-evidence-based care and excluded from your
`benefit. Thus, authorization is unbillable for this facility for medical oversight.
`In addition, based on Optum Level of Care Guidelines, there is no clinical
`information to support the need for half-day intensive outpatient care and support.
`You are medically stable. You are not reported to have any psychiatric issues that
`would prevent you from continuing treatment outside a half-day intensive
`outpatient monitored setting. You have been involved in treatment and you have
`had coping skills education. You can continue your recovery in a less intensive
`setting. At this point, continued services do not require the frequency and
`intensity of half-day intensive outpatient monitoring.
`…
`You could continue care with outpatient providers, utilizing an evidence based
`treatment modality.
`
`
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`7
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.9 Page 8 of 18
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`49. On March 13, 2020, A.H. submitted an appeal, on behalf of K.H., regarding the denial of
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`K.H.’s treatment at Uinta.
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`50. In A.H.’s level one appeal, he states in part,
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`This denial rationale is borderline nonsensical, given the fact that United
`acknowledges that [K.H.]’s level of care at [Uinta] is residential treatment, but
`then states that she did not require the intensive outpatient level of care. These
`two levels of care are two completely different levels of mental health care, and as
`such it appears that we have not been provided with a full and thorough review.
`…
`We also disagree with the United’s [sic] statement that [Uinta] is utilizing an
`unproven/experimental treatment modality, as residential treatment is a highly
`established and proven treatment setting for patients who require intensive,
`inpatient mental health treatment.
`…
`To help demonstrate that you are providing a full, fair, and thorough review of
`this appeal, please assign a reviewer who is board certified in adolescent
`psychiatry and who has experience treating adolescents and young adults with
`attention-deficit hyperactivity disorder (ADHD), post-traumatic stress disorder
`(PTSD), generalized anxiety disorder, social phobia, bipolar disorder, body
`dysmorphic disorder, alcohol dependence, cannabis dependence, opioid
`dependence, and other high risk behaviors in an intermediate residential setting.
`…
`Accordingly, we have the right to a response from you that is clear, specifically
`states the reasons for determination, references the plan language on which your
`decision is based, and explains what other information we could provide to you in
`order to perfect [K.H.]’s claim.
`…
`However, if you do not pay this claim based on the information we have
`presented in this appeal, we ask that you provide us with the specific reasons for
`your determination along with any corresponding supporting evidence. We would
`also like to request that you send us a copy of any administrative services
`agreements that exist, any clinical guidelines or medical necessity criteria utilized
`to evaluate the claim, any mental health, substance use disorder, skilled nursing
`facility, inpatient rehabilitation, or hospice medical necessity criteria used to
`administer our plan, and any reports or opinions provided to you from any
`physician or other processional about this claim.1
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`51. A.H. also explained why UBH’s statement that Uinta provides experimental treatment
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`was unfounded, stating:
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`1 Emphasis in original
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.10 Page 9 of 18
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`…based on this rationale we find it difficult to believe that any representative
`from United spoke with [Uinta] staff. [Uinta] is licensed by the state of Utah to
`provide Mental Health/Residential Treatment For Youth Female Clients Ages 12
`to 16. In order to receive this license, [Uinta] meets the state of Utah’s strict
`regulations regarding the operation of Residential Treatment Programs. In your
`response to this appeal, please explicitly confirm that you have reviewed the
`attached license…2
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`52. A.H. went on to explain that K.H.’s treatment at Uinta met the definition for a residential
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`treatment center in the insurance policy,
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`…[Uinta] meets our plan’s definition of a residential treatment program. While
`admitted to [Uinta], [K.] receives 24-hour supervision, structure, and treatment.
`Her program is intended to treat her multiple mental health disorders in a
`reasonable period of time. …she admitted for the treatment of her mental health
`disorders that were causing her to suffer from severe functional impairment across
`all areas of her life…
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`53. Lastly, A.H. explained how UBH and UHC appeared to be violating the Mental Health
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`Parity and Addiction Equity Act (“MHPAEA”) stating in part,
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`According to your denial letter, the intermediate behavioral health services that
`[K.H.] is receiving at [Uinta] are not a covered benefit under our plan. As [Uinta]
`is licensed by the state of Utah as a residential treatment center, it appears that
`United may be discriminating against [Uinta] based on provider specialty or some
`unnamed criteria that limits the scope of benefits for mental health care, as we
`cannot imagine that United would deny coverage for a similarly covered non-
`network skilled nursing facility.
`
`54. In a letter dated April 13, 2020, UBH upheld the denial of K.H.’s treatment at Uinta
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`stating in part,
`
`[UBH] is responsible for making benefit coverage determinations for mental
`health and substance use disorder services that are provided to UBH members.
`…
`As requested, I have completed an urgent appeal/grievance review on 04/10/2020
`11:02 AM EDT on a request we received on 03/25/2020.
`This review typically involves a telephone conversation with your provider.
`However, UBH attempts to reach your provider by phone were unsuccessful.
`Therefore, the review was based on the information available in your record and
`any additional information you may have submitted.
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`2 Emphasis in original
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`
`
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.11 Page 10 of 18
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`After fully investigating the substance of the appeal/grievance, including all
`aspects of clinical care involved in this treatment episode, I have determined that
`benefit coverage is not available for the following reason(s):
`You were admitted at a mental health residential treatment program. This appeal
`review is for a request for benefit coverage for this treatment effective 10/22/2019
`and thereafter.
`After reviewing the case notes, medical records and appeals materials, the patient
`did not require 24 hour care.
`You are medically stable. You have no evidence of substance use withdrawal.
`You do not have any psychiatric issues that would prevent you from continuing
`treatment outside a residential treatment center setting. You have been involved in
`residential treatment prior to this admission and you have learned many coping
`skills education. You can continue your recovery in a less intensive setting. At
`this point, continued services do not require the frequency and intensity of full
`day residential monitoring. Furthermore, you have not been seen on a regular
`basis by a psychiatrist which is an OPTUM requirement for residential care. The
`facility also has several treatment approaches which are not evidence based. Also,
`the medication regime noted is not consisted [sic] with the diagnoses provided in
`the medical records.
`…
`You could continue care with IOP and/or outpatient providers, utilizing an
`evidence-based treatment modality.
`
`55. On June 4, 2020, A.H., again appealed the denial of K.H.’s treatment at Uinta from her
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`admission on October 22, 2019, through discharge.
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`56. The June 4, 2020, appeal letter itself was 56-pages long and included hundreds of pages
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`of exhibits which encompassed letters of medical necessity, the entirety of the level one
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`appeal, multiple psychological assessments, medical records from several facilities prior
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`to K.H.’s treatment at Uinta and over 400 pages of medical records from Uinta.
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`57. A.H.’s explained the numerous administrative errors made by United. First, United
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`continued to send letters to A.H.’s incorrect address. United had continuously named
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`Uinta improperly, often referring to it as “Unita Academy” and “Unity Academy RTC.”
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`58. Additionally, United processed A.H.’s level one appeal as an urgent appeal/grievance
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`even though it was submitted several months after K. was admitted to Uinta and no
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.12 Page 11 of 18
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`urgent appeal was requested. Also, A.H.’s healthcare advocate spoke with UHC
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`specifically to request that it not be processed as an urgent appeal.
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`59. A.H. explained again how United had committed MHPAEA and ERISA violations, and
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`requested that United provide him with a full and through review of his appeal, and if it
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`maintained the denial, that it provide him with a full explanation.
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`60. In a letter dated July 9, 2020, UBH upheld the denial of K.H.’s treatment at Uinta, stating
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`in part,
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`An appeal request was received for 10 units of treatment in a mental health
`residential setting from 10/22/19 through 10/31/19. After reviewing the case notes
`and the submitted appeal information, there is insufficient clinical information
`provided to support the medical necessity for treatment in a mental health
`residential setting. Limited medical records for the appealed dates of service were
`provided. No initial psychiatric evaluation nor documentation of regularly-
`scheduled appointments with the facility psychiatrist were provided. Therefore, it
`does not appear that this program met the service intensity expected at the mental
`health residential level of care.
`In addition, authorization at this facility is not available due to service
`components not consistent with level of care guidelines.
`…
`I have determined that benefits coverage is not available for your admission to
`Unita [sic] Academy for the following date(s) of service: 10/22/2019 through
`10/31/2019.
`
`61. Despite A.H. submitting two appeals for all dates of service of K.H.’s treatment at Uinta,
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`United did not address any date past October 31, 2019, in their level two denial.
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`62. The July 9, 2020, letter from UBH continued to commit the same administrative errors it
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`had made in the past and barely addressed any of the arguments brought up in A.H.’s
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`level two appeal.
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`63. United did not provide A.H. with a full and fair review of his appeal.
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`64. On May 14, 2021, A.H. submitted a member response to the adverse benefit
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`determination letter to clarify the issues with UBH’s processing of K.H.’s Uinta claims.
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.13 Page 12 of 18
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`65. The May 14, 2021, letter explained that Uinta had been improperly “flagged” in UHC’s
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`system so that any services provided by the facility would be denied, regardless of the
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`medical necessity of the treatment in question and regardless of the fact that the facility
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`satisfied all of the requirements for a residential treatment center listed in the insurance
`
`policy.
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`66. A.H. requested a response to this letter, but as of the time of filing of this Complaint,
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`A.H. has not received one.
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`67. The Plaintiffs exhausted their pre-litigation appeal obligations under the terms of the Plan
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`and ERISA.
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`68. The denial of benefits for K.H.’s treatment was a breach of contract and caused A.H. to
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`incur medical expenses that should have been paid by the Plan in an amount totaling over
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`$200,000.
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`69. United failed to produce a copy of the plan documents including any medical necessity
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`criteria for mental health and substance use disorder treatment and for skilled nursing or
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`rehabilitation facilities despite A.H.’s multiple requests.
`
`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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`70. 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
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`United, acting as agent of the Plan, to “discharge [its] 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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`
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.14 Page 13 of 18
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`71. United and the Plan failed to provide coverage for K.H.’s treatment in violation of the
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`express terms of the Plan which promise benefits to employees and their dependents for
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`medically necessary treatment of mental health and substance use disorders.
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`72. 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).
`
`73. The denial letters produced by United do little to elucidate whether United conducted a
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`meaningful analysis of the Plaintiffs’ appeals or whether it provided them with the “full
`
`and fair review” to which they are entitled. United failed to substantively respond to the
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`issues presented in A.H.’s appeals and did not meaningfully address the arguments or
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`concerns that the Plaintiffs raised during the appeals process.
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`74. In fact, United’s denial letters rely on formulaic recitations and do not address the
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`arguments raised by A.H. in any capacity.
`
`75. United and the agents of the Plan breached their fiduciary duties to K.H. when they failed
`
`to comply with their obligations under 29 U.S.C. §1104 and 29 U.S.C. §1133 to act
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`solely in K.H.’s interest and for the exclusive purpose of providing benefits to ERISA
`
`participants and beneficiaries, to produce copies of relevant documents and information
`
`to claimants upon request, and to provide a full and fair review of K.H.’s claims.
`
`76. The actions of United and the Plan in failing to provide coverage for K.H.’s medically
`
`necessary treatment are a violation of the terms of the Plan and its medical necessity
`
`criteria.
`
`//
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.15 Page 14 of 18
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`SECOND CAUSE OF ACTION
`
`(Claim for Violation of MHPAEA Under 29 U.S.C. §1132(a)(3))
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`77. MHPAEA is incorporated into ERISA and is enforceable by ERISA participants and
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`beneficiaries as a requirement of both ERISA and MHPAEA. The obligation to comply
`
`with both ERISA and MHPAEA is part of United’s fiduciary duties.
`
`78. Generally speaking, MHPAEA requires ERISA plans to provide no less generous
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`coverage for treatment of mental health and substance use disorders than they provide for
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`treatment of medical/surgical disorders.
`
`79. MHPAEA prohibits ERISA plans from imposing treatment limitations on mental health
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`or substance use disorder benefits that are more restrictive than the predominant
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`treatment limitations applied to substantially all medical and surgical benefits and also
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`makes illegal separate treatment limitations that are applicable only with respect to
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`mental health or substance use disorder benefits. 29 U.S.C.§1185a(a)(3)(A)(ii).
`
`80. Impermissible nonquantitative treatment limitations under MHPAEA include, but are not
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`limited to, medical management standards limiting or excluding benefits based on
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`medical necessity; refusal to pay for higher-cost treatment until it can be shown that a
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`lower-cost treatment is not effective; and restrictions based on geographic location,
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`facility type, provider specialty, or other criteria that limit the scope or duration of
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`benefits for mental health or substance use disorder treatment. 29 C.F.R.
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`§2590.712(c)(4)(ii)(A), (F), and (H).
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`81. The medical necessity criteria used by United for the intermediate level mental health
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`treatment benefits at issue in this case are more stringent or restrictive than the medical
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`necessity criteria the Plan applies to analogous intermediate levels of medical or surgical
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`benefits.
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`82. Comparable benefits offered by the Plan for medical/surgical treatment analogous to the
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`benefits the Plan excluded for K.H.’s treatment include sub-acute inpatient treatment
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`settings such as skilled nursing facilities, inpatient hospice care, and rehabilitation
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`facilities.
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`83. For none of these types of treatment does United exclude or restrict coverage of
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`medical/surgical conditions by imposing restrictions such as an acute care requirement
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`for a sub-acute level of care. To do so, would violate not only the terms of the insurance
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`contract, but also generally accepted standards of medical practice.
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`84. When United and the Plan receive claims for intermediate level treatment of medical and
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`surgical conditions, they provide benefits and pay the claims as outlined in the terms of
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`the Plan based on generally accepted standards of medical practice.
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`85. United and the Plan evaluated K.H.’s mental health claims using medical necessity
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`criteria that deviate from generally accepted standards of medical practice. This process
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`resulted in a disparity because the Plan denied coverage for mental health benefits when
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`the analogous levels of medical or surgical benefits would have been paid.
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`86. Although Uinta is a licensed and accredited residential treatment facility which satisfies
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`the requirements in the Plan documents for coverage yet it is “flagged” by United as a
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`facility for which coverage is automatically denied.
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`87. United does not similarly “flag” analogous medical and surgical facilities for denial if
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`they are licensed and meet the requirements for coverage outlined in the Plan documents.
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`//
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.17 Page 16 of 18
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`88. Additionally, Defendants appeared to evaluate Uinta incorrectly as a “half-day intensive
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`outpatient monitored setting” as opposed to a sub-acute residential treatment center,
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`also leading to a near universal denial of benefits.
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`89. As another example of the Plan’s improper application of its criteria to evaluate the
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`treatment K.H. received, the Defendants relied on assertions such as “[y]ou are medically
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`stable” and “[y]ou have no evidence of substance use withdrawal” as a justification to
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`deny treatment.
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`90. In fact, being medically stable and not going through substance use withdrawal serves as
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`an indicator, rather than a contra-indicator, of the medical necessity of treatment in a non-
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`acute residential setting.
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`91. In this manner, the Defendants violate 29 C.F.R. §2590.712(c)(4)(i) because the terms of
`
`the Plan and the medical necessity criteria utilized by the Plan and United, as written or
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`in operation, use processes, strategies, standards, or other factors to limit coverage for
`
`mental health or substance use disorder treatment in a way that is inconsistent with, and
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`more stringently applied, than the processes, strategies, standards or other factors used to
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`limit coverage for medical/surgical treatment in the same classification.
`
`92. United and the Plan did not produce the documents the Plaintiffs requested to evaluate
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`medical necessity and MHPAEA compliance, nor did they address in any substantive
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`capacity the Plaintiffs’ allegations that United and the Plan were not in compliance with
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`MHPAEA.
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`93. The violations of MHPAEA by United and the Plan are breaches of fiduciary duty and
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`give the Plaintiffs the right to obtain appropriate equitable remedies as provided under 29
`
`U.S.C. §1132(a)(3) including, but not limited to:
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`Case 1:22-cv-00081-DBP Document 2 Filed 06/28/22 PageID.18 Page 17 of 18
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`(a) A declaration that the actions of the Defendants violate MHPAEA;
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`(b) An injunction ordering the Defendants to cease violating MHPAEA and requiring
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`compliance with the statute;
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`(c) An order requiring the reformation of the terms of the Plan and the medical necessity
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`criteria utilized by the Defendants to interpret and apply the terms of the Plan to
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`ensure compliance with MHPAEA;
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`(d) An order requiring disgorgement of funds obtained by or retained by the Defendants
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`because of their violations of MHPAEA;
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`(e) An order requiring an accounting by the Defendants of the funds wrongly withheld by
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`each Defendant from participants and beneficiaries of the Plan because of the
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`Defendants’ violations of MHPAEA;
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`(f) An order based on the equitable remedy of surcharge requiring the Defendants to
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`provide payment to the Plaintiffs as make-whole relief for their loss;
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`(g) An order equitably estopping the Defendants from denying the Plaintiffs’ claims in
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`violation of MHPAEA; and
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`(h) An order providing restitution from the Defendants to the Plaintiffs for their loss
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`arising out of the Defendants’ violation of MHPAEA.
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`94. In addition, Plaintiffs are entitled to an award of prejudgment interest pursuant to U.C.A.
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`§15-1-1, and attorney fees and costs pursuant to 29 U.S.C. §1132(g)
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`WHEREFORE, the Plaintiffs seek relief as follows:
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`1.
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`Judgment in t