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Case 4:21-cv-00093-DN Document 2 Filed 08/31/21 PageID.2 Page 1 of 12
`
`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
`
`Attorneys for Plaintiffs
`
`THE UNITED STATES DISTRICT COURT
`DISTRICT OF UTAH, CENTRAL DIVISION
`
`COMPLAINT
`
`Civil No. 4:21-cv-00093-DN
`
`PETER P., individually and on behalf of B.P.,
`a minor,
`
`Plaintiffs,
`
`vs.
`
`UNITED HEALTHCARE INSURANCE
`COMPANY OF ILLINOIS, UNITED
`BEHAVIORAL HEALTH/OPTUM, and the
`STAT ANESTHESIA SPECIALISTS, LTD
`MEDICAL BENEFIT PLAN,
`
`Defendants.
`
`Plaintiff Peter P. (“Peter”), individually and on behalf of B.P., a minor, through his
`
`undersigned counsel, complains and alleges against Defendants United HealthCare Insurance
`
`Company of Illinois and United Behavioral Health/OPTUM (collectively “UBH”) and the Stat
`
`Anesthesia Specialists, LTD Medical Benefit Plan (“the Plan”) as follows:
`
`PARTIES, JURISDICTION AND VENUE
`
`1. Peter P. (“Peter”) and B.P. (“B.”) are natural persons residing in Will County, Illinois.
`
`Peter is B.’s father.
`
`

`

`Case 4:21-cv-00093-DN Document 2 Filed 08/31/21 PageID.3 Page 2 of 12
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`2. United HealthCare Insurance Company is an insurance company doing business in Utah
`
`and throughout the United States and was the claims administrator as well as the
`
`fiduciary under ERISA for the Plan during the treatment at issue in this case.
`
`3. United Behavioral Health/OPTUM is an affiliate company specializing in mental health
`
`claims and handled the processing of the claims at issue in this case and was the entity
`
`responsible for the appeals process in this case.
`
`4. The Plan is a self-funded employee welfare benefits plan under 29 U.S.C. §1001 et. seq.,
`
`the Employee Retirement Income Security Act of 1974 (“ERISA”). Peter was a
`
`participant in the Plan and B. was a beneficiary of the Plan at all relevant times.
`
`5. B. received medical care and treatment at Turn About Ranch, Inc. (“TAR”) from August
`
`8, 2018 to November 30, 2018. TAR is a licensed residential treatment facility located in
`
`Utah, which provides sub-acute inpatient treatment to adolescents with mental health,
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`behavioral, and/or substance abuse problems.
`
`6. United HealthCare Insurance Company, acting in its own capacity or through its
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`subsidiary and affiliate (“UBH”) (or under the brand name Optum), denied claims for
`
`payment of B.’s medical expenses in connection with her treatment at TAR. This lawsuit
`
`is brought to obtain the Court’s order requiring the Plan to reimburse Peter for the
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`medical expenses he has incurred and paid for B’s treatment.
`
`7. This Court has jurisdiction over this case under 29 U.S.C. §1132(e)(1) and 28 U.S.C.
`
`§1331.
`
`8. Venue is appropriate under 29 U.S.C. §1132(e)(2) and 28 U.S.C. §1391(c) based on
`
`ERISA’s nationwide service of process and venue provisions, because UBH does
`
`business in Utah and the treatment at issue took place in Utah. In addition, venue in Utah
`
`
`
`2
`
`

`

`Case 4:21-cv-00093-DN Document 2 Filed 08/31/21 PageID.4 Page 3 of 12
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`will save the Plaintiffs costs in litigating this case. Finally, in light of the sensitive nature
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`of the medical treatment at issue, it is the Plaintiffs’ desire that the case be resolved in the
`
`State of Utah where it is more likely their privacy will be preserved.
`
`9. The remedies the Plaintiffs seek under the terms of ERISA and under the Plan are for the
`
`benefits due under the terms of the Plan, and pursuant to 29 U.S.C. §1132(a)(1)(B), for
`
`appropriate equitable relief under 29 U.S.C. §1132(a)(3) based on the Defendants’
`
`violation of the Mental Health Parity and Addiction Equity Act of 2008 ("MHPAEA"),
`
`an award of prejudgment interest, and an award of attorney fees and costs pursuant to 29
`
`U.S.C. §1132(g).
`
`BACKGROUND FACTS
`
`B.’s Developmental History and Medical Background
`
`10. B. was strong willed and aggressive from early childhood. She began exhibiting violent
`
`behaviors at a young age and had difficulty keeping friends. Her assaults on her brother
`
`prompted Peter and his wife to seek therapy for her when she was eight years old. She
`
`was also physically aggressive to her parents.
`
`11. When B. was ten years old, she was moved to a private Catholic school in hopes that
`
`more rigid rules and expectations would rein in some of her aggressive tendencies. They
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`also sought help from a new therapist and although B. received therapy for two more
`
`years, there was little progress.
`
`12. Peter and his wife continued to struggle with B.’s defiance. B. also began showing
`
`symptoms of depression. She lacked empathy and would laugh at inappropriate events.
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`She was drinking alcohol and engaging in unsafe sexual activity.
`
`
`
`3
`
`

`

`Case 4:21-cv-00093-DN Document 2 Filed 08/31/21 PageID.5 Page 4 of 12
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`13. The family again sought a new therapist and B. was diagnosed with Borderline
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`Personality Disorder with histrionic traits, Major Depressive Disorder, and Persistent
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`Depressive Disorder with anxious distress.
`
`14. B.’s condition continued to deteriorate and she was isolated, extremely anxious, and was
`
`engaging in self-harm. Psychiatric medications were prescribed but B. was constantly
`
`nauseated and irritable when taking the medications and did not appear to be getting any
`
`benefit from taking them.
`
`15. In February of 2018, B. was admitted to the hospital with suicidal ideation.
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`16. B.’s therapist recommended residential treatment as he believed her to be a danger to
`
`herself and others.
`
`17. B. was admitted to TAR on August 8, 2018.
`
`18. A psychiatric assessment was completed prior to B.’s admission and residential treatment
`
`was determined to be appropriate for her based on:
`
`Severe Individual Intra-psychic Disorder (mental, emotional and behavioral)
`Serious Developmental Disturbances
`Significant Disturbances in Environmental Relationships
`
`19. A Master Treatment Plan was created for B.’s stay at TAR which identified areas of
`
`concern and proposed specific treatment strategies for addressing each area.
`
`20. B. worked very hard during her treatment at TAR and although her progress was slow,
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`she made steady gains in managing her moods, taking responsibility, and developing
`
`coping skills.
`
`The Appeal
`
`21. Claims were submitted to UBH for coverage and payment of B.’s treatment at TAR.
`
`
`
`4
`
`

`

`Case 4:21-cv-00093-DN Document 2 Filed 08/31/21 PageID.6 Page 5 of 12
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`22. On August 28, 2018, UBH wrote to TAR and denied coverage for B.’s treatment on the
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`basis that “[t]he facility does not meet service expectations of your benefit plan,” and
`
`asserted that B.’s conditions did not meet the UBH Level of Care Guidelines for the
`
`Mental Health Residential Center Level of Care (“Guidelines”).
`
`23. Peter appealed the denial in a letter dated January 30, 2019. First, Peter outlined the
`
`requirements of ERISA in connection with the appeal process. Among other things,
`
`ERISA and its regulations require that all information submitted by a claimant be taken
`
`into consideration in evaluating an appeal. Peter argued that in order to understand B.’s
`
`conditions and the necessity of her treatment at TAR, it was critical that UBH include all
`
`of the information he provided with his appeal.
`
`24. Second, Peter discussed the requirements of MHPAEA. He noted that TAR was both a
`
`licensed residential treatment facility in the State of Utah and is a CARF certified
`
`treatment program. He referred to the definition of residential treatment found in his Plan
`
`and argued that TAR clearly met the definition.
`
`25. Peter argued that UBH was imposing limitations on claims for coverage for treatment of
`
`mental health conditions that were more restrictive than those for other types of
`
`intermediate care, a violation of MHPAEA.
`
`26. Peter then proceeded to discuss B.’s developmental background, the many instances of
`
`failed treatment at lower levels of care, and the recommendation of B.’s treating therapist,
`
`a psychologist, for residential treatment.
`
`27. Peter cited to therapy notes from B.’s treatment at TAR which demonstrate the medical
`
`necessity of her admission at TAR and her ongoing need for residential treatment during
`
`her stay at TAR.
`
`
`
`5
`
`

`

`Case 4:21-cv-00093-DN Document 2 Filed 08/31/21 PageID.7 Page 6 of 12
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`28. Finally, Peter compared the Guidelines with the coverage provisions found in his Plan
`
`and stated that where discrepancies existed between the two, the terms of the Plan should
`
`control.
`
`29. Peter requested that in the event UBH determined its initial denial had been correct, that
`
`he be provided with specific information about UBH’s decision-making process. He also
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`asked for copies of the administrative services agreement between UBH and his Plan, any
`
`clinical guidelines relied on by UBH, guidelines for other types of intermediate care
`
`covered by the Plan, and any reports by clinicians who had reviewed the claim.
`
`30. On March 7, 2019, UBH maintained it denial of coverage based on its assertion that B.
`
`did not meet the Guidelines for residential treatment and could have been treated at a
`
`lower level of care. UBH claimed that B. was capable of learning and using coping skills,
`
`was not engaging in self-harm, was not feeling like harming herself or others, and was
`
`participating in her therapeutic program, she was not eligible for coverage.
`
`31. The Plaintiffs exhausted their pre-litigation appeal obligations under the terms of the Plan
`
`and ERISA.
`
`32. The denial of benefits for B.’s treatment was a breach of contract and caused Peter to
`
`incur medical expenses that should have been paid by the Plan in an amount totaling over
`
`$70,000.
`
`33. UBH failed to provide the materials Peter had requested, including the medical necessity
`
`criteria for mental health and substance use disorder treatment and for skilled nursing or
`
`rehabilitation facilities.
`
`///
`
`///
`
`
`
`6
`
`

`

`Case 4:21-cv-00093-DN Document 2 Filed 08/31/21 PageID.8 Page 7 of 12
`
`FIRST CAUSE OF ACTION
`
`(Claim for Recovery of Benefits Under 29 U.S.C. §1132(a)(1)(B))
`
`34. ERISA imposes higher-than-marketplace quality standards on insurers and plan
`
`administrators. It sets forth a standard of care upon plan fiduciaries such as United, acting
`
`as agent of the Plan, to “discharge [its] duties in respect to claims processing solely in the
`
`interests of the participants and beneficiaries” of the Plan. 29 U.S.C. § 1104(a)(1).
`
`35. ERISA also underscores the particular importance of accurate claims processing and
`
`evaluation by requiring that administrators provide a “full and fair review” of claim
`
`denials and to engage in a meaningful dialogue with the Plaintiffs in the pre-litigation
`
`appeal process. 29 U.S.C. §1133(2).
`
`36. The denial letters produced by UBH do little to elucidate whether UBH conducted a
`
`meaningful analysis of Peter’s appeal or whether it provided him with the “full and fair
`
`review” to which he is entitled. UBH failed to substantively respond to the issues
`
`presented in Peter’s appeal and did not meaningfully address the arguments or concerns
`
`that he raised during the appeal process.
`
`37. UBH, as the agent of the Plan, breached its fiduciary duties to Peter and B. when it failed
`
`to comply with its obligations under 29 U.S.C. §1104 and 29 U.S.C. §1133 to act solely
`
`in the Plaintiffs’ 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 Plaintiffs’ claims.
`
`38. The actions of UBH, as agent for the Plan, in failing to provide coverage for B.’s
`
`medically necessary treatment are a violation of the terms of the Plan and its medical
`
`necessity criteria.
`
`
`
`7
`
`

`

`Case 4:21-cv-00093-DN Document 2 Filed 08/31/21 PageID.9 Page 8 of 12
`
`SECOND CAUSE OF ACTION
`
`(Claim for Violation of MHPAEA Under 29 U.S.C. §1132(a)(3))
`
`39. MHPAEA is incorporated into ERISA and is enforceable by ERISA participants and
`
`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.
`
`40. Generally speaking, MHPAEA requires ERISA plans to provide no less generous
`
`coverage for treatment of mental health and substance use disorders than they provide for
`
`treatment of medical/surgical disorders.
`
`41. MHPAEA prohibits ERISA plans from imposing treatment limitations on mental health
`
`or substance use disorder benefits that are more restrictive than the predominant
`
`treatment limitations applied to substantially all medical and surgical benefits and also
`
`makes illegal separate treatment limitations that are applicable only with respect to
`
`mental health or substance use disorder benefits. 29 U.S.C.§1185a(a)(3)(A)(ii).
`
`42. Impermissible nonquantitative treatment limitations under MHPAEA include, but are not
`
`limited to, medical management standards limiting or excluding benefits based on
`
`medical necessity; refusal to pay for higher-cost treatment until it can be shown that a
`
`lower-cost treatment is not effective; and restrictions based on geographic location,
`
`facility type, provider specialty, or other criteria that limit the scope or duration of
`
`benefits for mental health or substance use disorder treatment. 29 C.F.R.
`
`43. UBH’s medical necessity criteria for intermediate level mental health treatment benefits
`
`are more stringent or restrictive than the medical necessity criteria the Plan applies to
`
`intermediate level medical or surgical benefits.
`
`
`
`8
`
`

`

`Case 4:21-cv-00093-DN Document 2 Filed 08/31/21 PageID.10 Page 9 of 12
`
`44. Comparable benefits offered by the Plan for medical/surgical treatment analogous to the
`
`benefits the Plan excluded for B.’s treatment include sub-acute inpatient treatment
`
`settings such as skilled nursing facilities, inpatient hospice care, and rehabilitation
`
`facilities.
`
`45. For none of these types of treatment does the Plan exclude or restrict coverage of
`
`medical/surgical conditions based on medical necessity, geographic location, facility
`
`type, provider specialty, or other criteria in the manner UBH excluded coverage of
`
`treatment for B. at TAR.
`
`46. Specifically, in its review of B.’s claims, UBH’s reviewers improperly utilized acute
`
`medical necessity criteria to evaluate the non-acute treatment that B. received.
`
`47. UBH’s improper use of acute inpatient medical necessity criteria is revealed in the
`
`statements in UBH’s final denial letter such as saying that because B. was not a danger to
`
`herself or others, she did not meet the Guidelines for residential treatment.
`
`48. This improper use of acute inpatient criteria was a nonquantitative treatment limitation
`
`that cannot permissibly be applied to evaluate the sub-acute level of care that B. received.
`
`49. The Plan does not require individuals receiving treatment at sub-acute inpatient facilities
`
`for medical/surgical conditions to satisfy acute medical necessity criteria in order to
`
`receive Plan benefits.
`
`50. As another example of the Plan’s improper application of its criteria to evaluate the
`
`treatment B. received, UBH relied on assertions such as B. was participating in her
`
`therapeutic treatment as a justification to deny treatment. In fact, B.’s engagement in the
`
`program serves as an indicator rather than a contra-indicator of the medical necessity of
`
`treatment in a non-acute residential setting.
`
`
`
`9
`
`

`

`Case 4:21-cv-00093-DN Document 2 Filed 08/31/21 PageID.11 Page 10 of 12
`
`51. The treatment provided in an acute care environment is necessarily distinct from
`
`treatment provided in a non-acute environment. Utilizing acute criteria to evaluate a non-
`
`acute claim will result in a near universal denial of benefits, regardless of the medical
`
`necessity, clinical appropriateness, or nature of the treatment.
`
`52. The actions of UBH, as agent for the Plan, requiring conditions for coverage that do not
`
`align with medically necessary standards of care for treatment of mental health and
`
`substance use disorders and in requiring something above and beyond the licensing
`
`requirements for state law violate MHPAEA because the Plan does not impose similar
`
`restrictions and coverage limitations on analogous levels of care for treatment of medical
`
`and surgical conditions.
`
`53. When the Plan or its agent receive claims for intermediate level treatment of medical and
`
`surgical conditions, the Plan provides benefits and pays the claims as outlined in the
`
`terms of the Plan based on generally accepted standards of medical practice. UBH, as
`
`agent for the Plan, evaluated B.’s mental health claims using medical necessity criteria
`
`that deviate from generally accepted standards of medical practice.
`
`54. This process resulted in a disparity because the Plan denied coverage for mental health
`
`benefits when the analogous levels of medical or surgical benefits would have been paid.
`
`55. 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 UBH, as written or in operation,
`
`use processes, strategies, evidentiary standards, or other factors to limit coverage for
`
`mental health or substance use disorder treatment in a way that is inconsistent with, and
`
`more stringently applied, than the processes, strategies, evidentiary standards or other
`
`factors used to limit coverage for medical/surgical treatment in the same classification.
`
`
`
`10
`
`

`

`Case 4:21-cv-00093-DN Document 2 Filed 08/31/21 PageID.12 Page 11 of 12
`
`56. UBH and the Plan did not produce the documents Peter requested to evaluate medical
`
`necessity and MHPAEA compliance, nor did they address in any substantive capacity
`
`Peter’s allegations that UBH and the Plan were not in compliance with MHPAEA.
`
`57. The violations of MHPAEA by UBH and the Plan are breaches of fiduciary duty and also
`
`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:
`
`
`
`(a) A declaration that the actions of the Defendants violate MHPAEA;
`
`(b) An injunction ordering the Defendants to cease violating MHPAEA and requiring
`
`compliance with the statute;
`
`(c) An order requiring the reformation of the terms of the Plan and the medical necessity
`
`criteria utilized by the Defendants to interpret and apply the terms of the Plan to
`
`ensure compliance with MHPAEA;
`
`(d) An order requiring disgorgement of funds obtained by or retained by the Defendants
`
`as a result of their violations of MHPAEA;
`
`(e) An order requiring an accounting by the Defendants of the funds wrongly withheld by
`
`each Defendant from participants and beneficiaries of the Plan as a result of the
`
`Defendants’ violations of MHPAEA;
`
`(f) An order based on the equitable remedy of surcharge requiring the Defendants to
`
`provide payment to the Plaintiffs as make-whole relief for their loss;
`
`(g) An order equitably estopping the Defendants from denying the Plaintiffs’ claims in
`
`violation of MHPAEA; and
`
`(h) An order providing restitution from the Defendants to the Plaintiffs for their loss
`
`arising out of the Defendants’ violation of MHPAEA.
`
`
`
`11
`
`

`

`Case 4:21-cv-00093-DN Document 2 Filed 08/31/21 PageID.13 Page 12 of 12
`
`58. 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)
`
`WHEREFORE, the Plaintiffs seek relief as follows:
`
`1.
`
`Judgment in the total amount that is owed for B.’s medically necessary treatment at
`
`TAR under the terms of the Plan, plus pre and post-judgment interest to the date of
`
`payment;
`
`Appropriate equitable relief under 29 U.S.C. §1132(a)(3) as outlined in Plaintiffs’
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`Second Cause of Action;
`
`Attorney fees and costs incurred pursuant to 29 U.S.C. §1132(g); and
`
`For such further relief as the Court deems just and proper.
`
`DATED this 30th day of August, 2021.
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`By s/ Brian S. King
`
`Brian S. King
`
`Attorney for Plaintiffs
`
`
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`
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`2.
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`3.
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`4.
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`County of Plaintiffs’ Residence:
`Will County, Illinois
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`
`12
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`

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