The opinion
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8 UNITED STATES DISTRICT COURT
9 CENTRAL DISTRICT OF CALIFORNIA
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11 FRED G., Case No. 2:22-cv-05710-FLA (Ex)
12 Plaintiff,
MEMORANDUM OF DECISION
13 v. FOLLOWING BENCH TRIAL
14
ANTHEM BLUE CROSS LIFE AND
15 HEALTH INSURANCE CO., et al.,
16 Defendants.
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1 This action arises from the denial of a request for benefits under a tax-exempt,
2 multi-employer health plan (the “Plan”), governed by the Employee Retirement
3 Income Security Act of 1974, 29 U.S.C. § 1001, et seq. (“ERISA”). Plaintiff Fred G.
4 (“Plaintiff”) brings claims against Defendant Director’s Guild of America-Producer
5 Health Plan (“Defendant” or “DGA”)1 for: (1) recovery of benefits due under an
6 ERISA benefit plan, pursuant to 29 U.S.C. § 1132(a)(1)(B) (“§ 1132(a)(1)(B)”);2 and
7 (2) breach of fiduciary duty under § 1132(a)(3). Dkt. 13.
8 This matter came to bench trial on December 6, 2024.3 Dkt. 101. After
9 evaluating the evidence and considering the parties’ arguments, the court issues the
10 following findings of fact and conclusions of law,4 pursuant to Fed. R. Civ. P. 52(a).
11 FINDINGS OF FACT
12 I. The Plan
13 The Plan provides medical benefits for its participants and their covered
14 dependents. DGA_FG 001400.5 The Plan documents consist of the DGA-Producer
15 Pension and Health Plans Health Trust Agreement (“Trust Agreement,” id. at 001239–
16 94) and Summary Plan Description (“SPD,” id. at 001295–431). Plaintiff is a Plan
17
18
1 Plaintiff originally brought this action against DGA and former Defendant Anthem
19 Blue Cross Life and Health Insurance Company (“Anthem”). Dkt. 1. On September
17, 2024, Anthem was dismissed from the action with prejudice pursuant to the
20
parties’ Notice of Settlement. Dkt. 88.
21
2 29 U.S.C. § 1132 is also commonly referred to as ERISA § 502.
22
3 In the Ninth Circuit, actions to recover benefits under ERISA are adjudicated by
23 bench trial. Kearney v. Standard Ins. Co., 175 F.3d 1084, 1095 (9th Cir. 1999).
24 4 The court’s characterization of its determinations as a “finding of fact” or
“conclusion of law” is not controlling. To the extent a determination is characterized
25 as “conclusion of law” but is more properly characterized as a “finding of fact,” or
26 vice versa, substance shall prevail over form.
5 Citations to “DGA_FG” refer to the Plan’s administrative record, which was lodged
27
as Dkts. 46-1 and 65-1. Citations to “ANTHEM_FREDG” refer to Anthem’s
28 administrative record, which was lodged as Dkts. 47-1 through 47-12.
1 participant, and his son, J.G., is a beneficiary. Id. at 000001.
2 The Plan covers mental health and substance abuse services, including intensive
3 outpatient and residential treatments for substance abuse or mental health. Id. at
4 001360. All care (aside from covered preventive care services which are not at issue
5 here) must be “Medically Necessary,” as the term is defined in the Plan documents.
6 Id. at 001355. As relevant here:
7 A treatment, service or supply is Medically Necessary when it is:
8 Consistent with generally accepted medical practice within the
medical community for the diagnosis or direct care of symptoms,
9
Sickness or injury of the patient, … where and at the time the
10 treatment, service or supply is rendered (the determination of
“generally accepted medical practice” is the prerogative of the
11
Health Plan through consultation with appropriate authoritative
12 medical … practitioners);
13 Ordered by the attending licensed Physician…, and not solely for
[the participant or beneficiary’s] convenience, [his or her]
14
Physician, Hospital or other health care provider;
15
Consistent with professionally recognized standards of care in the
16 medical community with respect to the quality, frequency and
duration; and
17
The most appropriate and Cost-Efficient treatment, service or
18 supply that can be safely provided, at the most Cost-Efficient and
19 medically appropriate site and level of service.
20 Id. at 001415–16 (errors in original). Additionally, “[a] medical or dental service or
21 supply will be considered Cost-Efficient if it is no more costly than any alternative
22 appropriate service or supply when considered in relation to all health care expenses
23 incurred in connection with the service or supply.” Id. at 001412.
24 The Trust Agreement provides, in relevant part:
25 The Plan Trustees [the “Trustees”] shall have the sole complete and
26 discretionary authority [to] … (2) grant or deny, in whole or in part,
particular claims for benefits filed by participants or beneficiaries, in
27 accordance with the Plan Trustees’ interpretation of the Health Plan
28 and their fact findings relative to any such claims for benefits, (3)
1 gberannetf iocri adreiensy, cino vaecrcaogred aton cpee wrsiotnhs t hcela Pimlainn gT rtou sbteee psa’ ritnicteiprparnettsa otiro n of
2 the Health Plan and their fact findings relative to any such claim for
coverage, … (5) determine the type and duration of any benefits
3
payable to any participant or beneficiary, in accordance with the Plan
4 Trustees’ interpretation of the Health Plan and their fact findings
relative to any dispute over the type or duration of benefits payable,
5
(6) make any and all other findings of fact, construction,
6 interpretations and decisions relative to the Health Plan, and relative
to other rights, if any, of all persons, participants or beneficiaries to
7
benefits or coverage, and (7) construe and/or interpret any provisions
8 of the Health Plan. No Producer or group of Producers, the Guild,
any insurance company or any other person, … or other entity shall
9
have the authority to exercise any of the powers described in this
10 subsection. …
11 Id. at 001261–62.
12 The Trustees are jointly responsible for interpreting Plan provisions and
13 establishing rules and regulations governing entitlement of benefits and administration
14 of the Plan, id. at 001251–54, but may “allocate in writing fiduciary and non-fiduciary
15 responsibilities or duties among Trustees, including the allocation and delegation of
16 such responsibilities to committees and subcommittees of the Board[.]” Id. at 001263.
17 The Trust Agreement further authorizes the Trustees to “establish such committees as
18 they in their discretion deem proper and desirable for the proper administration of the
19 Health Plan and Health Fund,” and establishes the Benefits Committee as a standing
20 committee with the authority and responsibility for, inter alia, “[a]pproving benefit
21 awards, and hearing and determining claims appeals[.]” Id. at 001265–66.
22 “The general purpose of a committee is to study and debate issues that arise in
23 the administration of the Health Plan and the Health Fund and to make
24 recommendations thereon to the Board for action by the Board.” Id. at 001265.
25 “Notwithstanding this general limitation, the Board may, by resolution duly adopted,
26 allocate and delegate to a committee the authority to take final action in specified
27 areas; and in such instances the action of the committee shall have the same binding
28 effect as action by the full Board.” Id. At the bench trial, Defendant admitted there is
1 no evidence in the record to establish that the Board delegated to the Benefits
2 Committee the authority to take final action on approving benefit awards and hearing
3 and determining claims appeals, by a resolution duly adopted by the Board.
4 The Trust Agreement also authorizes the Trustees to “designate in writing
5 persons who are not Trustees to carry out fiduciary or non-fiduciary responsibilities or
6 duties of the Trustees[.]” Id. at 001263. Anthem was the designated claim
7 administrator for the residential treatment services at issue here. Id. at 000001. For
8 appeal administration, the Plan relies on third-party medical reviewers, such as the
9 Medical Review Institute of America (“MRI”), to make decisions related to benefits
10 determinations. Id.
11 II. J.G.’s History and Medical Treatment
12 J.G. was admitted to Outback Therapeutic Expeditions (“Outback”), an outdoor
13 behavioral health program, from February 17 to May 11, 2020. Id. at 000043. In a
14 Parent Questionnaire, his mother reported that J.G. began using nicotine at age 11 to
15 12 and used it almost daily prior to his admission to Outback. Id. at 000826. He also
16 began using marijuana at age 15 and used it two to four times per week. Id. His
17 mother further reported J.G. was “often aggressive at home,” would “break things,
18 yell, [and] cuss often,” was often angry and defensive, experienced mood swings
19 often, and was quick to anger without provocation. Id. at 000825.6
20
6 J.G.’s behavioral and treatment history are further detailed in the administrative
21
record. Most notably, Plaintiff reported J.G. began to exhibit aggressive and
22 hyperactive behavior, anger, frustration, depression, and anxiety after Plaintiff “went
through a very traumatic divorce process” when J.G. was nine years old. DGA_FG
23
000040. J.G.’s behavior “spiraled downward when he entered middle school in the
24 fall of 2015,” and only grew worse as he transitioned to high school, as he withdrew
further from his family and his oppositional defiance at home escalated. Id. at
25
000041–42. J.G.’s physical and verbal aggression further escalated during the fall and
26 winter of 2019, to the point that he “destroyed countless items in [their] home,”
“punched and kicked his closet doors until they were folded in half,” “destroyed lamps
27
and mirrors with his fists and by throwing other items at them,” “shattered [their] car
28
1 On March 25, 2020, J.G. underwent a comprehensive psychological evaluation
2 conducted by Abby Jenkins, Ph.D. (“Dr. Jenkins”), a licensed clinical psychologist.
3 Id. at 000786–804. Based on his history and test results, Dr. Jenkins diagnosed J.G.
4 with: (1) Attention-Deficit/Hyperactivity Disorder, Combined Presentation; (2)
5 Oppositional Defiant Disorder; (3) Unspecified Anxiety Disorder; (4) Cannabis Use
6 Disorder; (5) Parent-Child Relational Problem; and (6) Child Affected by Parental
7 Relationship Distress. Id. at 000801–02, 000804. Dr. Jenkins “strongly
8 recommended that following his stay at Outback, [J.G.] go on to a longer-term
9 residential therapeutic program, such as a therapeutic boarding school or boarding
10 school with collaborative supports, that can continue addressing each of the above
11 issues in depth.” Id. at 000802. Dr. Jenkins further noted that “[J.G.] remain[ed] at
12 heightened risk of emotional and behavioral dysregulation outside a structured
13 treatment setting.” Id.
14 On or around May 11, 2020, J.G. was admitted to Catalyst Residential
15 Treatment Center (“Catalyst”), a residential treatment center and boarding school
16 located in Utah.7 On May 14, 2020, Meghan Kunz (“NP Kunz”), PMHNP
17
18 visor mirror,” and “would thrash and punch the interior of the car when agitated,
making driving with him incredibly dangerous for the whole family.” DGA_FG
19 000042–43, 000388–94 (photographic evidence). Plaintiff additionally reported that
20 “[J.G.] stole a large sum of money from [them] on at least two occasions,” “[J.G.]
began leaving home for weeks at a time,” “[h]is drug use was also escalating and he
21 made plans to fake drug tests,” “[h]is anxiety, depression, and substance abuse had
22 gotten so out of control that [their] home environment was no longer safe, and his
ability to regulate his emotions had completely dissipated,” and “[his] anger and
23 aggression had gotten so dire, that there were numerous times [they considered]
24 calling the police.” Id.
7 The precise date of J.G.’s admission to Catalyst is unclear from the evidence in the
25
record. J.G. was discharged from Outback on May 11, 2020. DGA_FG 000043. NP
26 Kunz’s psychological medical evaluation states J.G. came to Catalyst directly from
Outback, but lists an admission date of “2/11/2020”—which would have been three
27
months before he was discharged from Outback. Id. at 000820, 000824. Other
28
1 (Psychiatric Mental Health Nurse Practitioner) conducted a psychiatric medication
2 evaluation of J.G. Id. at 000823. NP Kunz concurred with Dr. Jenkins’ diagnoses and
3 recommended the following pharmacological interventions:
4 MEDICATIONS: No medications will be started at this time.
5 Rationale/ Counseling/ Education Risk vs. Benefit: I highly
recommend this program for the individual, family, group, and
6
recreational therapy. The academic and Substance use treatment that
7 is offered here at this program will benefit him greatly. Catalyst will
also allow him to work on his emotional regulation, coping skills,
8
cognitive and behavioral issues, and solution focused motives as well
9 as other treatment approaches.
10 Id. J.G. remained at Catalyst for treatment from the date of his admission until he was
11 discharged on June 4, 2021. Id. at 000949.
12 III. Denial of Benefits and Appeals
13 In or around May 2020, Anthem received a coverage request for residential
14 psychiatric care at Catalyst for the seven day-period beginning May 15, 2020, which
15 Anthem approved as “medically necessary under [Plaintiff’s] benefit plan.” DGA_FG
16 000009–11. On May 22, 2020, Anthem approved an extension request for an
17 additional 7 days of residential psychiatric care, beginning May 22, 2020. Id. On
18
19 records from Catalyst state J.G. was admitted on “05/11/2019.” Id. at 000949.
20 Defendant, in turn, contends J.G. was admitted on May 15, 2020, which was the first
date of service Plaintiff requested and Anthem approved. Dkt. 86 (Def. Opening Trial
21 Br.) at 7; DGA_FG 000001, 000009–18; ANTHEM_FREDG002582.
22 Based on the evidence submitted, the court finds: (1) J.G. was admitted to Catalyst on
or around May 11, 2020; (2) Plaintiff requested approval of residential treatment
23
beginning on or around May 15, 2020; and (3) any conflicting dates reflect
24 typographical errors. The record indicates J.G. was discharged from Outback on May
11, 2020, and admitted to Catalyst directly. DGA_FG 000820, 000824. Furthermore,
25
the dates listed in Catalyst’s records, “05/11/2019” and “2/11/2020,” differ from May
26 11, 2020 (5/11/2020) by one year and one key on a keyboard number pad
respectively—suggesting typographical errors. Regardless, the precise date of J.G.’s
27
admission to Catalyst is not material to the court’s ultimate findings of fact and
28 conclusions of law.
1 June 4, 2020, Anthem approved an additional 4 days of residential psychiatric care as
2 “medically necessary under [Plaintiff’s] benefit plan,” while denying 3 days of
3 requested care as “Not Medically Necessary.” Id. at 000012–17.
4 The denial letter states the claim was reviewed by David Naimark, M.D. (“Dr.
5 Naimark”), using the “MCG guideline Residential Behavioral Health Level of Care,
6 Child or Adolescent (ORG: B-902-RES)” (the “MCG Guidelines”). Id. at 000016–17;
7 see also ANTHEM_FREDG000817–22. The denial letter and Dr. Naimark’s notes
8 offered the following rationale for the denial decision:
9 The plan clinical criteria considers ongoing residential treatment
medically necessary for those who are a danger to themselves or
10
others (as shown by hearing voices telling them to harm themselves or
11 others or persistent thoughts of harm that cannot be managed at a
lower level of care). This service can also be medically necessary for
12
those who have a mental health condition that is causing serious
13 problems with functioning. (For example, being impulsive or
abusive, very poor self care, not sleeping or eating, avoidance of
14
personal interactions, or unable to perform usual obligations). In
15 addition, the person must be willing to stay and participate, and is
expected to either improve with this care, or to keep from getting
16
worse. The information we have does not show your condition is
17 likely to further improve with this care or get worse without it. For
this reason, the request is denied as not medically necessary. There
18
may be other treatment options to help you, such as outpatient
19 services. You may want to discuss these with your doctor. It may
help your doctor to know we reviewed the request using the MCG
20
guideline Residential Behavioral Health Level of Care, Child or
21 Adolescent (ORG: B-902-RES).
22 DGA_FG 000016; ANTHEM_FREDG000821.
23 Plaintiff submitted a level one appeal to Anthem along with supporting
24 documentation including: an appeal letter, 384 pages of medical records from
25 Outback, 21 pages of medical records from Catalyst, Dr. Jenkins’ psychological
26 assessment report, and letters of medical necessity. DGA_FG 000023–25. The Plan
27 forwarded the appeal and supporting documentation to Anthem on February 2 through
28 4, 2021, id. at 000837–40, and Kayla Fisher, M.D. (“Dr. Fisher”) conducted the
1 review, ANTHEM_FREDG000814–16.
2 Anthem upheld the denial decision in a letter, dated March 11, 2021, which
3 stated in relevant part:
4 We reviewed all the information that was given to us before with the
first request for coverage. We also reviewed all that was given to us
5
for the appeal. Your doctor wanted you to stay longer in residential
6 treatment center care. You were getting this because you had been at
risk for serious harm without 24 hour care. We understand that you
7
would like us to change our first decision. Now we have new
8 information from the medical record plus letters. We still do not think
this is medically necessary for you. We believe our first decision is
9
correct for the following reason: after the treatment you had, you were
10 no longer at risk for serious harm that needed 24 hour care. You
could have been treated with outpatient services. We based this
11
decision on the MCG guideline Residential Behavioral Health Level
12 of Care, Child or Adolescent (ORG: B-902-RES).
13 DGA_FG 000847–48.
14 On April 20, 2021, the Plan requested MRI review the level one appeal and all
15 clinical documentation received to date, and answer whether the services were
16 medically necessary as defined by the Plan. Id. at 000854–55. James Kimball, M.D.
17 (“Dr. Kimball”) conducted the review using the following medical guidelines in his
18 rationale: (1) the American Academy of Child and Adolescent Psychiatry, American
19 Association of Community Psychiatrists, Child and Adolescent Level of Care
20 Utilization System, Child and Adolescent Version 20, July 2019 (“CALOCUS”); and
21 (2) the Child and Adolescent Service Intensity Instrument, American Academy of
22 Child and Adolescent Psychiatry, September 2018 (“CASII”). Id. at 000860–61.
23 In a report, dated April 26, 2021, Dr. Kimball opined:
24 The psychiatric residential treatment from 06/02/20 to discharge is not
25 considered medically necessary in accordance with the Plan definition
of medical necessity.
26
The notes indicate that the patient has a complicated psychiatric
27 history. He has a long history of aggression and anger towards family
members. He had been acting out at home and using substances. He
28
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2 which appears to have helped the patient. He was admitted to a
residential treatment facility on 05/11/20.
3
Unfortunately, it appears that very few clinical notes from the
4
residential facility have been provided for review. There are brief
5 notes from 10/16/20, 09/29/20 which seemed to indicate the patient’s
participation in an activity. There are therapy notes from 05/15/20,
6
05/18/20, 05/21/20 and 05/25/20. Nursing notes were provided from
7 05/15/20. There was also a medication evaluation from 05/15/20. No
other notes were provided from the residential treatment facility,
8
including an initial history and physical.
9
The notes indicate that the patient is at some risk of harm, moderate
10 functional impairment, significant comorbidity, moderately stressful
environment, limited support in the environment, moderate response
11
to treatment, and incompletely engaged. As such, per the Child and
12 Adolescent Level of Care Utilization System for Psychiatric and
Addiction Services, coverage of continued residential level of care has
13
not been met. It is not clear why the patient cannot be managed at a
14 lower level of care.
15 Given that residential level of care was not the most cost efficient
treatment, service or supply than can be safely provided at the most
16
cost efficient and medically appropriate site and level of service, the
17 plan language of medically necessary has not been met.
18 Id. at 000861. The Plan notified Plaintiff by letter, dated May 11, 2021, that the
19 appeal was denied and that he could submit a further appeal. Id. at 000865–67.
20 On September 3, 2021, Plaintiff submitted a level two appeal along with
21 supporting documentation including: an appeal letter, a copy of Plaintiff’s prior
22 appeal, and 246 pages of additional records from Catalyst for the period between June
23 2, 2020 through June 4, 2021. Id. at 000885–1200. On September 28, 2021, the Plan
24 sent the second-level appeal and all submitted medical records to MRI for medical
25 necessity review, which was again conducted by Dr. Kimball. Id. at 001209–15. In a
26 report, dated October 4, 2021, Dr. Kimball opined again that continued residential
27 treatment was not medically necessary in accordance with the Plan’s definition of the
28 term. Id. at 001213.
1 Dr. Kimball’s report for the level two appeal reproduced many of the sentences
2 and paragraphs from his first report verbatim, and again cited CALOCUS and CASII
3 as the medical guidelines used in the review. Compare id. at 000865–67 with
4 001211–15. Both reports included a “Conflict of Interest Statement,” in which he
5 certified that he: “To the best of his[] knowledge, ha[d] not had any prior involvement
6 in the denial/appeal process for the case, regardless of whether the involvement was
7 on behalf of MRI[] or any other peer review vendor[.]” Id. at 001214.
8 By letter, dated October 7, 2021, the Plan informed Plaintiff that his appeal
9 would be presented to the Benefits Committee of the Board at its next meeting, and
10 that “[t]he Trustees will consider all of the evidence and testimony submitted in
11 support of [Plaintiff’s] appeal, but [Plaintiff would] not be entitled to make an in-
12 person appearance at the meeting.” Id. at 001224.
13 On March 1, 2022, the Benefits Committee denied Plaintiff’s appeal “pursuant
14 to Health Plan rules and determinations by Anthem and MRI confirming that the
15 residential treatment [was] not medically necessary as defined by the Health Plan.”
16 Id. at 001235–36. In its supplemental response to Plaintiff’s Interrogatory No. 7,
17 Defendant admitted that, “for mental health claims, [the Plan’s chief medical advisor,
18 Dr. Steven M. Simons,] and the Benefits Committee rely upon the medical specialties
19 of Anthem and MRI’s reviewing physicians to support the claim reasoning[.]” Dkt.
20 68-2 at 13.
21 CONCLUSIONS OF LAW
22 I. Standard of Review for Denial of Benefits
23 As a threshold matter, the parties debate the standard of review applicable to
24 this matter. “A denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed
25 under a de novo standard unless the benefit plan gives the administrator or fiduciary
26 discretionary authority to determine eligibility for benefits or to construe the terms of
27 the plan.” Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). “[F]or
28 a plan to alter the standard of review from the default of de novo to the more lenient
1 abuse of discretion, the plan must unambiguously provide discretion to the
2 administrator.” Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir.
3 2006) (en banc) (citing Kearney, 175 F.3d at 1090). “ERISA plans are insufficient to
4 confer discretionary authority on the administrator when they do not grant any power
5 to construe the terms of the plan.” Id. at 964.
6 Since Anthem has been dismissed from the action already, the court focuses
7 solely on whether the Benefits Committee possessed the requisite discretionary
8 authority to warrant an abuse of discretion standard of review. See Dkt. 86 at 13 n. 4;
9 Dkt. 87 at 13. The Trust Agreement expressly gives the Board of Trustees the
10 authority to determine eligibility for benefits and to construe and/or interpret the terms
11 of the Plan. DGA_FG 001261–62. Although the Trust Agreement allows the Board
12 of Trustees to allocate and delegate responsibilities to committees and subcommittees
13 of the Board, including the authority to take final action in specified areas, any such
14 allocation or delegation must be in writing and “by resolution duly adopted.” Id. at
15 001263, 001265.
16 Defendant does not identify any separate resolution, writing, or evidence that
17 clearly establishes the Board vested the Benefits Committee with the requisite
18 discretionary authority, and admitted at trial that there is no evidence of such a
19 resolution in the record. Accordingly, the court finds the Board of Trustees did not
20 delegate its discretionary authority to the Board’s Benefits Committee
21 unambiguously, and that the denial of benefits is subject to de novo review.8 See Dan
22 C. v. Anthem Blue Cross Life and Health Ins. Co., No. 24-3203, 2025 WL 1554927, at
23 *1 (9th Cir. June 2, 2025) (affirming trial court’s ruling that the Plan’s denial of
24
25
8 Although the court finds de novo review applies here, the court’s ultimate
26 determinations remain the same under discretionary review, as the court finds below
that Defendant deprived Plaintiff of the opportunities to engage in “meaningful
27
dialogue” on the issue of medical necessity and receive a “full and fair” review of the
28 denial of his claim.
1 continued residential treatment is subject to de novo review, in a parallel action
2 involving the same claims and similar facts).9
3 II. Denial of Benefits
4 A. Medical Necessity
5 Plaintiff has met his burden to prove the residential treatment at issue was
6 medically necessary with credible, persuasive evidence. Anthem determined J.G.’s
7 admission to residential psychiatric care was medically necessary when it approved
8 his initial request for such care. DGA_FG 000009 (“This approval means that, based
9 on the information given to us, the service is considered medically necessary under
10 your benefit plan”). The medical necessity of J.G.’s admission is also established by
11 evidence in the record, including independent assessments by Dr. Jenkins (id. at
12 000786–804), NP Kunz (id. at 000820–23), and Dr. Naimark
13 (ANTHEM_FREDG000816), as well as Plaintiff’s letters of medical necessity
14 (DGA_FG 000828–35).10 Accordingly, the court must determine whether (a) J.G.’s
15
16
9 The Ninth Circuit additionally recognized that “[t]hough the Plan delegates the task
of ‘determining claims appeals’ to the Committee and provides that the Committee
17 ‘will have discretion to deny or grant the appeal in whole or part,’ this language falls
18 short of the unambiguous delegation contemplated by [Ninth Circuit] precedent.”
Dan C., 2025 WL 1554927, at *1 (citing Ingram v. Martin Marietta Long Term
19 Disability Income Plan, 244 F.3d 1109, 1112–13 (9th Cir. 2001)).
20 10 E.g., DGA_FG at 000802 (Dr. Jenkins’ assessment report, dated March 11, 2020:
“It is strongly recommended that following his stay at Outback, [J.G.] go on to a
21
longer-term residential therapeutic program, such as a therapeutic boarding school or
22 boarding school with collaborative supports, that can continue addressing each of [the
diagnosed] issues in depth.”); id. at 820 (NP Kunz’s psychiatric medication
23
evaluation, dated May 14, 2020: “I highly recommend [Catalyst’s] program for the
24 individual, family, group, and recreational therapy. … Catalyst will also allow him to
work on his emotional regulation, coping skills, cognitive and behavioral issues, and
25
solution focused motives as well as other treatment approaches.”); id. at 000829 (letter
26 by Heather Lin, M.D., dated July 20, 2020: “Given the lack of sustainable
improvement with outpatient treatment modalities and deterioration in [J.G.’s]
27
behavior, a higher level of care was recommended for [J.G.] and referral to
28
1 continued residential treatment was medically necessary, or (b) J.G. satisfied the
2 requirements for discharge from residential care.
3 Once a patient has been admitted to residential care under the MCG Guidelines,
4 continued residential care is “generally needed” until one of the following two
5 situation applies:
6 o Residential care is no longer necessary due to adequate patient
stabilization or improvement as indicated by ALL of the
7
following:
8 Risk status acceptable as indicated by ALL of the following:
9 Danger to self or others manageable….
10 Patient and supports understand follow-up treatment and
crisis plan.
11
Provider and supports are sufficiently available at lower
12 level of care.
13 Patient, as appropriate, can participate as needed in
monitoring at available lower level of care.
14
Functional status acceptable as indicated by 1 or more of the
15 following:
No essential function is significantly impaired.
16
An essential function is impaired, but impairment is
17
manageable at available lower level of care.
18 Medical needs absent or manageable at available lower level of
care as indicated by ALL of the following:
19
Adverse medication effects absent or manageable
20
Medical comorbidity absent or manageable …
21
Medical complications absent or manageable
22 Treatment goals for level of care met.
23 / / /
24
educational consultant/ placement specialist Randi Klein was provided to the family to
25
help guide them towards the appropriate residential treatment facilities”); id. at
26 000831 (letter by Randi Klein, MS, LMFT, LPCC, dated July 7, 2020: “I
recommended that J.G. attend Outback Therapeutic Expeditions. After this program,
27
the treatment team, including myself, recommended that [J.G.] attend[] a residential
28 treatment facility … called Catalyst Residential Treatment Center in Utah.”).
1 o fRoellsoidweinntgia: l care is no longer necessary due to 1 or more of the
2 Higher level of care is indicated (eg, patient condition has
3 deteriorated or more intensive supervision is necessary to
address clinical needs).
4
Lack of improvement indicates need for long-term custodial
5 facility.
6 Patient or guardian refuses treatment.
7 DGA_FG 000072–73 (emphasis in original, footnotes and references omitted).
8 Anthem’s denial letter, dated June 4, 2020, and Dr. Naimark’s notes offered the
9 following rationale in support of the denial decision:
10 The plan clinical criteria considers ongoing residential treatment
medically necessary for those who are a danger to themselves or
11
others…. This service can also be medically necessary for those who
12 have a mental health condition that is causing serious problems with
functioning. … In addition, the person must be willing to stay and
13
participate, and is expected to either improve with this care, or to keep
14 from getting worse. The information we have does not show your
condition is likely to further improve with this care or get worse
15
without it. For this reason, the request is denied as not medically
16 necessary.
17 DGA_FG 000016; ANTHEM_FREDG000821.
18 Dr. Naimark did not state continued residential care was no longer necessary
19 due to adequate patient stabilization or improvement, or discuss how J.G. met the
20 factors for discharge on this basis.11 See ANTHEM_FREDG 000817–22. To the
21
22 11 Defendant contends “the Plan’s decision, based on informed medical reviews, was
correct because J.G. posed no harm to himself or others justifying 24/7 residential
23
treatment care.” Dkt. 86 at 1. That, however, is not the standard for discharge from
24 residential treatment under the MCG Guidelines. DGA_FG 000072–73. Although
Defendant’s stated justification could potentially support denial of care under the
25
Admission Guidelines of the MCG Guidelines, see id. at 000072, Defendant provides
26 no evidence or legal authority to establish that residential treatment is no longer
medically necessary under the MCG Guidelines and an admitted patient should be
27
discharged once the patient’s clinical status has improved to the point that the patient
28
1 contrary, Dr. Naimark noted J.G.’s chart indicated he had a very chronic diagnosis of
2 oppositional defiant disorder and would not be expected to improve with a short-term
3 intervention, and that the treatment “[was] expected to be a long term placement of
4 180 days.” Id. at 000822. This should have resulted in a determination that discharge
5 based on adequate patient stabilization or improvement was not warranted, and
6 continued residential treatment was medically necessary, because J.G.’s medical needs
7 were not manageable at an available lower level of care.12 See DGA_FG 000073.13
8 Dr. Fisher’s assessment on the level one appeal, ANTHEM_FREDG000815–
9 16, likewise, does not support discharge under the MCG Guidelines, as Dr. Fisher
10 agreed with and relied on Dr. Naimark’s analysis without discussing how this analysis
11 was consistent with the MCG Guidelines for discharging a patient due to adequate
12 patient stabilization or improvement. Accordingly, the court finds neither Dr.
13
14
would no longer qualify for admission. Defendant, thus, fails to establish J.G.’s
15 continued residential care was no longer medically necessary on this basis.
16
12 In particular, neither Dr. Naimark nor Dr. Fisher found, or identified any evidence
to support a finding, that J.G.’s medical comorbidity and substance-related disorder
17 became absent or manageable as of June 2, 2020, as would be required to justify
18 discharge under the MCG Guidelines. See DGA_FG 000073. While Defendant notes
Dr. Fisher stated in her report that J.G. “was not using substances while in the
19 program,” Dkt. 92 at 7 (citing ANTHEM_FREDG000815), the fact that J.G. did not
20 use illegal narcotics and other substances while in residential treatment is insufficient
to establish that his “[s]ubstance-related disorder [was] absent or manageable,” when
21 coverage for continued residential treatment was denied.
22 13 Although Dr. Naimark’s analysis could potentially have supported discharge on the
grounds that a “[h]igher level of care [was] indicated” or “[l]ack of improvement
23
indicate[d] need for long-term custodial facility,” see DGA_FG 000073, neither
24 Anthem nor DGA offered this as a basis for the denial of coverage. To the extent
Defendant may argue continued residential treatment was denied on this basis, such
25
denial would constitute a violation of the Plan’s obligations to: “(1) provide adequate
26 notice in writing to [Plaintiff], setting forth the specific reasons for such denial,
written in a manner calculated to be understood by the participant, and (2) afford a
27
reasonable opportunity to [Plaintiff] for a full and fair review … of the decision
28 denying the claim.” 29 U.S.C. § 1133; Dan C., 2025 WL 1554927, at *2.
1 Naimark nor Dr. Fisher’s reports are sufficient to establish lack of medical necessity
2 or justify Anthem and the Plan’s denial of coverage for continued residential care.
3 Defendant additionally argues its denial decision was appropriate because Dr.
4 Kimball determined independently that “the Plan’s medical necessity standard for
5 continued residential care coverage had not been met and that J.G.’s treatment could
6 have been managed at a lower level of care.” Dkt. 86 at 14. Dr. Kimball, however,
7 did not evaluate J.G.’s continued treatment under the MCG Guidelines and relied
8 instead on CALOCUS and CASII—neither of which were included in the
9 administrative record. While the parties have submitted a copy of the CALOCUS
10 manual for the court’s review, Dkt. 69-2, they have not provided the court with the
11 CASII guidelines. Dr. Kimball’s expert opinions, thus, lack adequate foundation and
12 are inadmissible. See Daubert v. Merrell Dow Pharms., Inc., 509 U.S. 579, 592
13 (1993).
14 Even if the court were to consider Dr. Kimball’s opinion based on the
15 CALOCUS guidelines alone, Dr. Kimball’s assessment would not constitute a valid
16 basis to deny continued residential treatment as of June 2, 2020, since CALOCUS
17 specifies that patient reviews should not be conducted more often than “every three
18 months for extended care services such as residential treatment facilities.” Dkt. 69-2
19 at 30. As it is undisputed that J.G.’s admittance to residential treatment on or around
20 May 14, 2020 was medically necessary, it was improper for Dr. Kimball to apply
21 CALOCUS to determine whether continued residential care was medically necessary
22 less than three weeks later.
23 Furthermore, Dr. Kimball’s reports clearly indicate his assessments were of
24 J.G.’s conditions as of the date of the reports—after J.G. had received months of
25 residential treatment. See DGA_FG 000853 (discussing J.G.’s treatment notes from
26 Catalyst up to and including October 16, 2020, before concluding: “The notes indicate
27 that the patient is at some risk of harm, moderate functional impairment, significant
28 comorbidity, moderately stressful environment, limited support in the environment,
1 moderate response to treatment, and incompletely engaged”) (emphasis added); id. at
2 001213 (discussing treatment notes up to and including May 25, 2021, before
3 concluding the same).14 Accordingly, these assessments do not support his conclusion
4 that continued residential treatment was not medically necessary as of June 2, 2020,
5 when coverage for continued residential treatment was denied. If anything, Dr.
6 Kimball’s assessments demonstrate J.G.’s residential treatment at Catalyst was
7 successful and resulted in sufficient patient stabilization and improvement to allow
8 him to be treated at a lower level of care by the time of his discharge.
9 Defendant argues Plaintiff’s medical necessity letters have no probative value
10 regarding whether the Plan’s standard for medical necessity was met, because they fail
11
14 Since CALOCUS requires an evaluator to “select the highest score or rating in
12
which at least one of the criteria is met,” Dkt. 69-2, Dr. Kimball’s evaluations would
13 only be consistent with his own discussion of J.G.’s “complicated psychiatric history”
14 if they were of J.G.’s status at the date of the reports, rather than when coverage for
continued residential treatment was denied. For example, dimension V of CALOCUS
15 concerns “Resiliency and Treatment History.” Id. at 17–18. Dr. Kimball noted J.G.
16 had “a history of significant outpatient treatment with minimal results,” DGA_FG
000861, 001212, which is consistent with a finding of poor resiliency and/or response
17 to treatment (rating 4, which includes: “b- Previous treatment has not achieved
18 complete remission of symptoms or optimal control of symptoms even with intensive
and/or repeated exposure to treatment” and “c- Attempts to maintain whatever gains
19 that were attained in intensive treatment have limited success, even for limited time
20 periods or in structured settings”). Dr. Kimball, however, found J.G. had a “moderate
response to treatment” (rating 3, which includes: “b- Previous experience in treatment
21 at low level of intensity has not been successful in relief of symptoms or optimal
22 control of symptoms” and “c- Recovery has been maintained for moderate periods of
time, but only with strong professional or peer supports or in structured settings”).
23 DGA_FG 000861, 001212.
24 Evaluating J.G.’s conduct and mental health history based on his “complicated
psychiatric history” alone, without considering the post-denial treatment notes from
25
Catalyst, would result in a CALOCUS level of care recommendation of level five:
26 medically monitored residence-based services—which is the level of care Plaintiff
requested. See Dkt. 69-2 at 8–38. This assessment is also consistent with Anthem’s
27
initial determination that J.G.’s admission to residential treatment was medically
28 necessary.
1 to address whether J.G.’s treatment at Catalyst was the most appropriate and cost-
2 efficient treatment, service, or supply that could be safely provided, at the most cost-
3 efficient and medically appropriate site and level of service. Dkt. 86 at 15–17.
4 According to Defendant, “[a]lthough many of the clinicians asserted that J.G.’s
5 parents had exhausted all treatment options, none of the treating clinicians considered
6 the option of [intensive outpatient program (‘IOP’)] or [partial hospitalization program
7 (‘PHP’)] care, even on a trial basis, prior to beginning at Outback/Catalyst, or
8 following the initial approved stay at Catalyst.” Id. at 16 (emphasis omitted).
9 Defendant does not offer any argument or explanation why Plaintiff would need
10 to establish IOP or PHP care were not more cost-effective, given that Anthem, itself,
11 found J.G.’s admission to residential treatment at Catalyst was medically necessary
12 under the Plan without any discussion of IOP or PHP care. See DGA_FG 000009.
13 Defendant, likewise, does not identify any medical guidelines that state that a patient
14 that has been admitted to residential treatment should be removed from such treatment
15 after less than three weeks of care and required to participate in IOP or PHP care to
16 receive continued residential treatment. To the contrary, the MCG Guidelines
17 establish that such removal is improper unless the patient satisfies the Discharge
18 Guidelines, and CALOCUS precludes reevaluation before the patient has received
19 three months of care. Defendant’s argument, thus, fails.
20 Accordingly, the court concludes Defendant violated the terms of the Plan by
21 determining J.G.’s continued residential treatment was not medically necessary and
22 denying J.G. coverage for continued residential care. Plaintiff, thus, is entitled to
23 benefits.
24 B. Full and Fair Opportunity for Review
25 The Plan also failed to conform to the claims procedure required by statute and
26 regulation. Under federal law, an ERISA plan must:
27 (1) provide adequate notice in writing to any participant or beneficiary
whose claim for benefits under the plan has been denied, setting forth
28
1 be understood by the participant, and
(2) afford a reasonable opportunity to any participant whose claim for
2
benefits has been denied for a full and fair review by the appropriate
3 named fiduciary of the decision denying the claim.
4 29 U.S.C. § 1133.
5 ERISA requires “a meaningful dialogue between ERISA plan administrators
6 and their beneficiaries.” Booton v. Lockheed Med. Benefit Plan, 110 F.3d 1461, 1463
7 (9th Cir. 1997) (citing 29 C.F.R. 2560.503-1(g)(1) (former subd. (f))). “If benefits are
8 denied in whole or in part, the reason for the denial must be stated in reasonably clear
9 language, with specific reference to the plan provisions that form the basis for the
10 denial; if the plan administrators believe that more information is needed to make a
11 reasoned decision, they must ask for it.” Id.
12 “A plan administrator abuses its discretion if it renders a decision without any
13 explanation, construes provisions of the plan in a way that conflicts with the plain
14 language of the plan, or fails to develop facts necessary to its determination.”
15 Anderson v. Suburban Teamsters of N. Ill. Pension Fund Bd. of Trs., 588 F.3d 641,
16 649 (9th Cir. 2009). “The general rule … is that a court will not allow an ERISA plan
17 administrator to assert a reason for denial of benefits that it had not given during the
18 administrative process.” Harlick v. Blue Shield of Cal., 686 F.3d 699, 719–20 (9th
19 Cir. 2012). “The remedy for an improper denial of benefits due to a procedurally
20 deficient review of a claim is the same as the remedy for an improper denial of
21 benefits due to a substantively incorrect medical necessity determination.” Dan C.,
22 2025 WL 1554927, at *2 n. 2 (citing Salomaa v. Honda Long Term Disability Plan,
23 642 F.3d 666, 680–81 (9th Cir. 2011)).
24 In Dan C., 2025 WL 1554927, at *2, the Ninth Circuit affirmed the lower
25 court’s ruling, in an unrelated action against Anthem and the Plan involving similar
26 facts, that the Plan deprived the plaintiff of a full and fair review due to a
27 “fundamental failure to explain to [the Dan C. plaintiff] that the Plan’s operative
28 definition of medical necessity required attempting lower levels of care—namely, an
1 intensive outpatient program [IOP] or partial hospitalization program [PHP]—before
2 residential treatment.” Although “the Plan’s medical reviewers noted internally that
3 IOP or PHP services would be more appropriate for [the minor] than residential
4 treatment,” subsequent letters from the Plan to the Dan C. plaintiff indicated only that
5 “residential treatment was not medically necessary because [the minor] did not pose a
6 danger to himself or others and did not experience serious problems with daily
7 functioning—and therefore could be treated with ‘outpatient services’ instead.” Id. at
8 *3. Because IOP or PHP were not mentioned to the plaintiff in writing until after the
9 minor’s discharge from the residential treatment facility, the Ninth Circuit held
10 Anthem and the Plan’s “inadequate notice deprived Plaintiff of the opportunity to
11 ‘answer[] in time’ the Plan’s questions about lower levels of care, to engage in
12 ‘meaningful dialogue’ on the issue of medical necessity, and to receive a ‘full and
13 fair’ review of the denial of his claim.” Id. (citing Salomaa, 642 F.3d at 679–80).
14 The denial letter here was nearly identical to the letter in Dan C., and stated:
15 “There may be other treatment options to help you, such as outpatient services,”
16 DGA_FG 000016, without explaining: (1) why J.G.’s prior “significant” outpatient
17 treatments, including at Outback, were insufficient; (2) what program or types of
18 outpatient programs Anthem and the Plan believed J.G. should attempt prior to
19 continued residential treatment;15 (3) why Anthem believed J.G. needed to interrupt
20 his residential treatment to attempt IOP or PHP services before he could receive
21 continued care; (4) why such interruption was medically necessary or appropriate
22 considering Anthem had approved his admission to residential treatment already; (5)
23 how J.G. was logistically or practically supposed to attempt IOP or PHP services to
24
25
15 Here, as in Dan C., 2025 WL 1554927, at *3, neither Anthem nor the Plan
26 mentioned IOP or PHP to Plaintiff in writing until four months after J.G. was
discharged from Catalyst on June 4, 2021. See DGA_FG 001217 (letter denying
27
Plaintiff’s second-level appeal, dated October 7, 2021, stating for the first time that
28 “the most cost effective and efficient modality for the treatment is [PHP].”
1 obtain continued residential treatment, given that he was undergoing the previously
2 approved residential treatment when continued coverage was denied; and/or (6) what
3 evidence and analysis led Dr. Naimark and Anthem to conclude “[r]esidential care
4 [was] no longer necessary due to adequate patient stabilization or improvement” under
5 the MCG Guidelines, such that J.G. could be discharged to a lower level of care.
6 Here, as in Dan C., 2025 WL 1554927, at *2, Defendant’s inadequate notice
7 deprived Plaintiff of the opportunity to “answer[] in time” the Plan’s questions about
8 lower levels of care, engage in “meaningful dialogue” on the issue of medical
9 necessity, and receive a “full and fair” review of the denial of his claim. Defendant’s
10 subsequent letters to Plaintiff were similarly deficient and failed to provide Plaintiff a
11 “full and fair” review. See DGA_FG 000847–52, 000865–72, 001216–23.16
12 The court, therefore, finds Plaintiff’s benefits were improperly denied due to a
13 procedurally deficient review of his claim and that Plaintiff is entitled to benefits on
14 this additional basis.
15 III. Breach of Fiduciary Duty
16 “ERISA also provides a claim for breach of fiduciary duty.” Castillo v. Metro.
17 Life Ins. Co., 970 F.3d 1224, 1228 (9th Cir. 2020). “Just as trust law imposes duties
18 on trustees, ERISA imposes duties on plan fiduciaries.” Id. “A fiduciary, for
19 instance, must ‘discharge his duties with respect to a plan solely in the interest of the
20 participants and beneficiaries and ... with the care, skill, prudence, and diligence ... of
21 a prudent man.” Id. (brackets omitted) (quoting 29 U.S.C. § 1104(a)(1)). “An
22 individual bringing a claim under § 1132(a)(3) may seek ‘appropriate equitable relief,’
23 which refers to ‘those categories of relief’ that, traditionally speaking … were
24
25
16 Notably, the Plan failed to offer any explanation for why MRI reviewed the appeals
26 under CALOCUS and CASII, rather than the MCG Guidelines, see DGA_FG
000865–67, 001216–18, which further deprived Plaintiff of the opportunity to engage
27
in “meaningful dialogue” on the issue of medical necessity and receive a “full and
28 fair” review of his appeals.
1 typically available in equity.” Id. at 1229 (cleaned up) (quoting CIGNA Corp. v.
2 Amara, 563 U.S. 421, 439 (2011)).
3 “Because § 1132(a)(3) acts as a safety net, offering appropriate equitable relief
4 for injuries caused by violations that [ERISA] § 502 does not elsewhere adequately
5 remedy, relief is not available under § 1132(a)(3) where Congress elsewhere provided
6 adequate relief for a beneficiary’s injury.” Id. (cleaned up). “Thus, a claimant may
7 not bring a claim for denial of benefits under § 1132(a)(3) when a claim under
8 § 1132(a)(1)(B) will afford adequate relief.” Id. “Claims under § 1132(a)(1)(B) and
9 § 1132(a)(3), however, may proceed simultaneously so long as there is no double
10 recovery.” Id. (quotation marks and citation omitted).
11 In the First Amended Complaint, Plaintiff seeks equitable relief including an
12 order “enjoining the Plan from using level of care guidelines that fall below
13 reasonable standards in the medical community, either as written or as applied, or
14 both,” in addition to his request to recover the full amount of benefits that were
15 denied. Dkt. 13 ¶ 56. Plaintiff’s Opening Trial Brief requests the court “fashion
16 appropriate relief so that neither Plaintiff nor other DGA plan participants are
17 subjected to such claims handling mis-administration.” Dkt. 87 at 22. Defendant
18 responds that any request for relief on behalf of a non-party is improper because
19 Plaintiff did not bring a class action and has not alleged any basis for third-party
20 standing. Dkt. 92 at 15.
21 Plaintiff did not demonstrate at trial that either he or J.G. are likely to have
22 future claims denied based on the level of care guidelines applied here, or that any
23 form of equitable relief is warranted for non-party Plan participants or beneficiaries.
24 The court, therefore, holds Plaintiff is not entitled to any relief beyond recovery of the
25 benefits due, prejudgment interest, and reasonable attorney’s fees and costs, and that
26 “[equitable] relief is not available [to Plaintiff] under § 1132(a)(3).” See Castillo, 970
27 F.3d at 1229; see also Dan C., 2025 WL 1554927, at *3.
28 / / /
1 CONCLUSION
2 Plaintiff's request to overturn Defendant’s denial of benefits is GRANTED, and
3 | judgment is entered in Plaintiffs favor on his § 1132(a)(1)(B) claim. Plaintiffs
4 | request for additional equitable relief under § 1132(a)(3) is DENIED. Plaintiff may
5 | bring a motion for attorney’s fees and costs as permitted under ERISA, 29 U.S.C.
6 | § 1132(a)(1)(B), (g)(1). Plaintiff shall file a proposed judgment and e-mail a Word
7 | format version directly to the court’s chambers email address within five (5) business
8 | days of the filing of this Order.
9
10 IT IS SO ORDERED.
11
12 | Dated: July 7, 2025
13 FERNANDO L. AENLLE-ROCHA
United States District Judge
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