United States District Court, D. Utah
TONY M. AND A.M., Plaintiffs,
UNITED HEALTHCARE INSURANCE COMPANY, and the EMC CORPORATION EMPLOYEE WELFARE BENEFITS PLAN, Defendants.
MEMORANDUM DECISION AND ORDER
BENSON UNITED STATES DISTRICT JUDGE.
the court is Defendants' Motion to Dismiss or, in the
alternative, to stay the proceedings. Dkt. No. 15. The motion
has been fully briefed by both parties, and the court has
considered the facts and arguments set forth in those
filings. Pursuant to civil rule 7-1(f) of the United States
District Court for the District of Utah Rules of Practice,
the court elects to determine the motion on the basis of the
written memoranda and finds that oral argument would not be
helpful or necessary. DUCivR 7-1(f).
following facts are taken from Plaintiffs' complaint.
They are accepted as true and viewed in the light most
favorable to the plaintiff as the non-moving party. GFF
Corp. v. Associated Wholesale Grocers, Inc., 130 F.3d
1381, 1384 (10th Cir. 1997).
Tony M. is a participant in the EMC Corporation Employee
Welfare Benefits Plan (“the Plan”), which is
administered by United Healthcare Insurance Company
(“United”). Id. ¶¶ 2-3.
Plaintiff A.M. is a beneficiary of the Plan. Id.
¶ 3. Tony adopted A. when he was seven years old, after
A. had endured years of poverty, neglect, and abuse in El
Salvador. Dkt. No. 2 ¶¶ 9-10. In the years
following his adoption, A. suffered from numerous
psychological conditions and displayed exceptionally violent
behavior. Id. ¶¶ 11-15. After A. seriously
injured Tony, he was placed in juvenile detention where he
exhibited traits indicative of psychotic personality
disorders. Id. ¶ 16. On the recommendation of
detention center staff, he was enrolled in a treatment
facility for six months and then sent to Sunnycrest Youth
Ranch for an additional 18 months. Id. ¶ 17.
After returning home and initially reacclimating well, A.
started once again to exhibit violent and sexually aggressive
behavior. Id. ¶ 18. On the recommendation of
his psychiatrist, he was admitted to Elk River Treatment
Program on April 24, 2016. Id. ¶¶ 18-20.
letter dated August 15, 2016, United denied payment for
A.'s treatment at Elk River. Id. ¶ 21. The
letter stated, “According to [A.'s] insurance
guidelines his treatment is considered to be custodial at
this time and custodial care is not a covered benefit.”
Id. The letter continued, “Based on our Level
of Care Guideline for Mental Health Residential
Rehabilitation Level of Care, it is my determination that no
further authorization [for treatment at Elk River] can be
provided from 08/09/2016.” Id. It then
informed Tony of his right to appeal the adverse decision.
February 8, 2017, about six months after receiving the
notice, Tony appealed the denial of payment, arguing that
United had violated his ERISA rights and A.'s treatment
was medically necessary. Id. ¶¶ 22-24. In
response, he received a letter dated March 9 upholding the
denial of payment. Id. ¶ 27. That letter stated
that Tony had “exhausted all available internal
appeal/grievance options, ” but informed him that he
could request an independent external review. Id.
¶ 27. It contained no additional justifications for
upholding the denial of payment. Id. The following
month, Tony submitted a “level two appeal, ” in
which he wrote that he had contacted United over the phone
and had been told that his “level one appeal” was
never processed “because it had been mistakenly
classified as a provider appeal.” Id. ¶
28. Tony reiterated many of his arguments from the
“level one appeal, ” and maintained that A.'s
treatment at Elk River was medically necessary, submitting
several letters in support of that contention. Id.
10, 2017, about two weeks after Tony submitted his
“level two appeal, ” United sent Tony a letter
from external reviewer MCMC upholding the denial of payment.
Id. ¶ 32. That letter included the following
language: “The independent Board Certified Physician
determined that the services at this level of care are not
medically necessary . . . . In this case, the Residential
Treatment Program level of care is not medically necessary
and is considered to be custodial care.” Id.
The Plaintiffs then filed this action in the United States
District Court for the District of Utah on March 8, 2019, and
Defendants filed a Motion Dismiss on June 21, 2019. Dkt. No.
TO DISMISS STANDARD
considering a motion to dismiss, all well-pleaded factual
allegations, as distinguished from conclusory allegations,
are accepted as true and viewed in the light most favorable
to the non-moving party. GFF Corp. v. Associated
Wholesale Grocers, Inc., 130 F.3d 1381, 1384
(10th Cir. 1997). Plaintiff must provide
“enough facts to state a claim to relief that is
plausible on its face.” Bell Atl. Corp. v.
Twombly, 550 U.S. 544, 570 (2007). This court's role
“is not to weigh potential evidence that the parties
might present at trial, but to assess whether the
plaintiff's complaint alone is legally sufficient.”
Miller v. Glanz, 948 F.2d 1526, 1565
(10th Cir. 1991).
Pending Class Action
first move for dismissal of all claims based on A.'s
membership in a certified plaintiff class in the pending
class action captioned Wit v. United Behavioral
Health, 3:14-cv-2346-JCS (N.D. Cal. May 21, 2014). Dkt.
No. 15 at 11. In opposition, Plaintiffs contend that because
only United and the Plan (and not United Behavioral Health)
are named as defendants in this action, Plaintiff does not
belong to the class in Wit. Dkt. No. 20 at 5-6. The
fact that Plaintiffs chose not to name United Behavioral
Health (“UBH”) as a defendant does not itself
exclude them from the certified class in Wit. The
relevant certified class is defined as follows:
Any member of a health benefit plan governed by ERISA whose
request for coverage of residential treatment services for a
mental illness or substance abuse disorder was denied by
United, in whole or in part, on or after May 22, 2011, based
upon United's Level of ...