1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

ERISA COMPLAINT

Lisa Counters, SBN 016436

lisa@countersfirm.com

The Counters Firm, P.C.

4809 E. Thistle Landing Drive, Ste. 100

Phoenix, AZ 85044

(602) 490-0030 (voice)

(888) 683-8397 (fax)

Attorneys for Plaintiff

UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

William Culberson, 

Plaintiff,

v. 

UnitedHealthcare Insurance Company, 

The Proctor & Gamble Retiree Health 

Plan, and Proctor & Gamble Company,

Defendants.

Case No.: 

CLAIM FOR ERISA PLAN BENEFITS

Plaintiff, William Culberson, as to all relevant times, alleges as follows 

against Defendants UnitedHealthcare Insurance Company, The Proctor & Gamble 

Retiree Health Plan, and Proctor & Gamble Company. 

PRELIMINARY ALLEGATIONS

1. “Jurisdiction” - This action is brought under 29 U.S.C. §§ 1132(a), (e), 

(f) and (g) of the Employee Retirement Income Security Act of 1974 (hereinafter 

“ERISA”) as it involves a claim by Plaintiff for employee benefits under an 

employee benefit plan regulated and governed under ERISA. Jurisdiction is 

predicated under these code sections as well as 28 U.S.C. § 1331 as this action 

Case 2:15-cv-01651-JAT Document 1 Filed 08/21/15 Page 1 of 6
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

2

ERISA COMPLAINT

involves a federal question. This action is brought for the purpose of obtaining 

benefits under the terms of an employee benefit plan, enforcing Plaintiff’s rights 

under the terms of an employee benefit plan, and to clarify Plaintiff’s rights to future 

benefits under the employee benefit plan administered by Defendant. Plaintiff seeks 

relief, including but not limited to: payment of benefits, prejudgment and postjudgment interest, and attorneys’ fees and costs.

2. Plaintiff, William Culberson, is and was at all relevant times a resident 

of the City of Mesa, Maricopa County, Arizona. Thus, venue is proper in this 

judicial district pursuant to 29 U.S.C. § 1132(e)(2).

3. Plaintiff was at all relevant times a covered participant under Defendant 

Proctor & Gamble Retiree Health Plan (“the Plan”), an employee welfare benefit 

plan regulated by ERISA and pursuant to which Plaintiff is entitled to health care 

benefits (Identification No. R07167313). Mr. Culberson is a covered participant

under the Plan. 

4. The Plan transacts business and has participants in the state of Arizona, 

thus can be found in the District of Arizona. 

5. Plaintiff is informed and believes that Defendant The Proctor & 

Gamble Company has its principal place of business in the State of Ohio, and is 

authorized to transact and is transacting business in this judicial district, the District 

of Arizona, and can be found in the District of Arizona.

6. Plaintiff is informed and believes that Defendant UnitedHealthcare 

Insurance Company (“UHIC”) has its principal place of business in the State of 

Minnesota, and is authorized to transact and is transacting business in this judicial 

district, the District of Arizona, and can be found in the District of Arizona.

7. The claims at issue herein were specifically administered in this 

judicial district. Thus, venue is proper in this judicial district pursuant to 29 U.S.C. 

§ 1132(e)(2) (special venue rules applicable to ERISA actions).

Case 2:15-cv-01651-JAT Document 1 Filed 08/21/15 Page 2 of 6
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

3

ERISA COMPLAINT

FIRST CAUSE OF ACTION AGAINST DEFENDANTS

FOR DENIAL OF BENEFITS

8. Plaintiff incorporates by reference paragraphs 1 through 7 as though 

fully set forth herein.

9. Mr. Culberson is a 69-year old man who in 2007 was diagnosed and 

treated for Hodgkin’s Lymphoma. Treatment rendered to Mr. Culberson included 

extensive radiation to his neck and head. 

10. Beginning in 2010, Mr. Culberson began experiencing the loss of teeth 

due to decay under the gum line. In fact, since 2010, Mr. Culberson has lost seven 

teeth. Mr. Culberson is informed and believes that the treatment he received for 

Hodgkin’s Lymphoma destroyed his salivary glands, causing improper maintenance 

of his root resulting inevitable tooth decay. 

11. In November 2013, Mr. Culberson’s treating dentist advised him that 

one of his upper front teeth was going to have to be pulled due to the same underthe-gum root decay. Due to the tooth’s location, Mr. Culberson opted to pursue a 

restorative treatment plan. Mr. Culberson was also advised that the tooth decay he 

was experiencing was more than likely caused by the radiation therapy he received 

to treat Hodgkin’s Lymphoma. 

12. On November 22, 2013, Mr. Culberson received the restorative dental 

services prescribed to him by his treating dentist.

13. Mr. Culberson was informed and believed that his Plan covered the 

remaining costs of the applicable dental work and that all claims made under the 

Plan would need to be first submitted to Medicare and then to UHIC. 

14. On March 6, 2014, Mr. Culberson filed a claim for dental services 

received by his treating dentist. 

15. On May 2, 2014, Noridian, Medicare’s claims administrator, denied 

Mr. Culberson’s claim. 

Case 2:15-cv-01651-JAT Document 1 Filed 08/21/15 Page 3 of 6
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

4

ERISA COMPLAINT

16. On May 15, 2014, Mr. Culberson visited Dr. Richard T. Hoppe at the 

Stanford Cancer Center Department of Radiation Oncology. Dr. Hoppe submitted a 

new claim for the dental services received on November 22, 2013. 

17. On June 12, 2014, Mr. Culberson received Explanations of Benefits 

denying his claims on the grounds that his Plan does not cover “this dental 

expense.” 

18. On July 15, 2014, Mr. Culberson submitted an appeal to UHIC 

indicating that he would need to seek restorative treatment for additional upper 

molars, six of which had fallen out due to the side effects of chemotherapy.

18. On August 18, 2014, UHIC upheld the denial in response to Mr. 

Culberson’s appeal stating in relevant part that: “The plan provides dental services 

for traumatic accidental injuries to natural teeth. The dental decay that you have 3 

years after your radiation and chemotherapy treatment is not considered traumatic 

accidental injury.”

19. On October 17, 2014, Mr. Culberson submitted a second level appeal to 

UHIC. 

20. On November 20, 2014, UHIC upheld its initial denial despite citing 

language from the terms of Mr. Culberson’s Plan which states that the Plan covers 

dental care required for the direct treatment of a medical condition limited to: Direct 

treatment of acute traumatic Injury, cancer or cleft palate. (emphasis added). 

21. On December 20, 2014, Mr. Culberson wrote to UHIC for access to all 

documents, records and any other relevant information regarding the claim for 

dental services, pursuant to the language of UHIC’s second level appeal denial 

letter.

22. On January 7, 2015, UHIC sent Mr. Culberson a letter isolating all of 

the terms of his Plan which apply to covered and excluded dental services under his 

Plan, providing no further explanation or any reasonable access to appropriate 

internal clinical guidelines or protocols.

Case 2:15-cv-01651-JAT Document 1 Filed 08/21/15 Page 4 of 6
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

5

ERISA COMPLAINT

23. Defendants wrongfully denied Plaintiff’s claim for benefits, in the 

following respects, among others:

(a) Failure to pay medical benefit payments due to Plaintiff at a time when 

Defendants knew, or should have known, that Plaintiff was entitled to those 

benefits under the terms of the Plan;

(b) Failure to provide reasonable explanations of the bases relied on under 

the terms of the Plan documents, in relation to the applicable facts, laws and 

Plan provisions, for the denial of the claims for medical benefits; and

(c) Failure to properly and adequately investigate the merits of the claims.

24. Plaintiff is informed and believes and thereon alleges that Defendants

wrongfully denied the claims for benefits by other acts or omissions of which 

Plaintiff is presently unaware, but which may be discovered in this litigation and 

which Plaintiff will immediately make Defendants aware of once said acts or 

omissions are discovered by Plaintiff.

25. Following the denial of the claims for benefits under the Plan, Plaintiff 

exhausted all administrative remedies required under ERISA, and performed all 

duties and obligations on her part to be performed.

26. As a proximate result of the denial of medical benefits, Plaintiff has 

been damaged in the amount of all of the bills incurred for the treatment and has 

been prevented from receiving any further restorative treatment for lost teeth.

27. As a further direct and proximate result of this improper determination 

regarding the dental claims, Plaintiff, in pursuing this action, has been required to 

incur attorneys’ costs and fees. Pursuant to 29 U.S.C § 1132(g)(1), Plaintiff is 

entitled to have such fees and costs paid by Defendants.

28. Due to the wrongful conduct of Defendants, Plaintiff is entitled to 

enforce his rights under the terms of the Plan and to clarify his rights to future 

benefits under the terms of the Plan.

Case 2:15-cv-01651-JAT Document 1 Filed 08/21/15 Page 5 of 6
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

6

ERISA COMPLAINT

SECOND CAUSE OF ACTION AGAINST DEFENDANT

FOR EQUITABLE RELIEF

29. Plaintiff refers to and incorporates by reference paragraphs 1 through 

28 as though fully set forth herein.

30. As a direct and proximate result of the failure of the Defendants to pay 

claims for medical benefits, and the resulting injuries and damages sustained by 

Plaintiff as alleged herein, Plaintiff is entitled to and hereby requests that this Court 

grant Plaintiff the following relief pursuant to 29 U.S.C. § 1132(a)(1)(B):

(a) Restitution of all past benefits due to Plaintiff, plus prejudgment 

and post-judgment interest at the lawful rate; and

(b) Such other and further relief as the Court deems necessary and 

proper to protect the interests of Plaintiff under the Plan.

REQUEST FOR RELIEF

Wherefore, Plaintiff prays for judgment against Defendant as follows:

1. Payment of health benefits due to Plaintiff under the Plan;

2. Pursuant to 29 U.S.C. § 1132(g), payment of all costs and attorneys’ 

fees incurred in pursuing this action;

3. Payment of prejudgment and post-judgment interest at the highest rate 

allowable by law; and

4. For such other and further relief as the Court deems just and proper.

DATED: August 21, 2015 THE COUNTERS FIRM, P.C. 

BY: /s/ Lisa J. Counters

Lisa J. Counters

Case 2:15-cv-01651-JAT Document 1 Filed 08/21/15 Page 6 of 6