Court Opinion

ID: 9959322
Source: CourtListenerOpinion
Date Created: 2024-04-11 16:00:43.297208+00
Date Added: 2024-06-11T08:18:16.407609
License: Public Domain

FOR PUBLICATION

   UNITED STATES COURT OF APPEALS
        FOR THE NINTH CIRCUIT

RYAN S., individually and on behalf   No. 22-55761
of all others similarly situated,
                                         D.C. No.
              Plaintiff-Appellant,    8:19-cv-01363-
                                         JVS-KES
 v.

UNITEDHEALTH GROUP, INC., a             OPINION
Delaware corporation; UNITED
HEALTHCARE SERVICES, INC., a
Minnesota corporation; UNITED
HEALTHCARE INSURANCE
COMPANY, a Connecticut
corporation; UHC OF CALIFORNIA,
a California corporation; UNITED
HEALTHCARE SERVICES, LLC, a
Delaware limited liability company;
UNITED BEHAVIORAL HEALTH,
INC., a California corporation;
OPTUMINSIGHT, INC., a Delaware
corporation; OPTUM SERVICES,
INC., a Delaware corporation;
OPTUM, INC., a Delaware
corporation,

              Defendants-Appellees.
2              RYAN S. V. UNITEDHEALTH GROUP, INC.

        Appeal from the United States District Court
           for the Central District of California
         James V. Selna, District Judge, Presiding

           Argued and Submitted October 19, 2023
                    Pasadena, California

                       Filed April 11, 2024

Before: Richard R. Clifton and Gabriel P. Sanchez, Circuit
     Judges, and Edward R. Korman, * District Judge.

                    Opinion by Judge Clifton

                          SUMMARY **

                              ERISA

    The panel reversed in part and affirmed in part the
district court’s judgment, and remanded for further
proceedings, in a case in which Ryan S. brought a putative
class action under the Employee Retirement Income
Security Act of 1974 (“ERISA”) against UnitedHealth
Group, Inc. and its subsidiaries (collectively,
“UnitedHealthcare”).

*
 The Honorable Edward R. Korman, United States District Judge for the
Eastern District of New York, sitting by designation.
**
  This summary constitutes no part of the opinion of the court. It has
been prepared by court staff for the convenience of the reader.
              RYAN S. V. UNITEDHEALTH GROUP INC.              3

    Ryan S. alleged that UnitedHealthcare applies a more
stringent review process to benefits claims for outpatient,
out-of-network mental health and substance use disorder
(“MH/SUD”) treatment than to otherwise comparable
medical/surgical treatment. Ryan S. asserted that by doing
so, UnitedHealthcare has violated the Paul Wellstone and
Pete Domenici Mental Health Parity and Addiction Equity
Act of 2008 (“Parity Act”), 29 U.S.C. § 1185a, in the process
also breaching its fiduciary duty and violating the terms of
his plan.
    The district court granted UnitedHealthcare’s motion to
dismiss under Federal Rule of Civil Procedure 12(b)(6)
based primarily on its conclusions that Ryan S. (1) failed to
allege that his claims had been “categorically” denied and
(2) insufficiently identified analogous medical/surgical
claims that he had personally submitted and
UnitedHealthcare had processed more favorably.
    The panel concluded that Ryan S. adequately stated a
claim for a violation of the Parity Act. The panel explained
that an ERISA plan can violate the Parity Act in different
ways, including by applying, as Ryan S. alleged here, a more
stringent internal process to MH/SUD claims than to
medical/surgical claims. A plaintiff presenting that type of
contention may be able to allege a plausible claim without
having to allege a categorical practice or differential
treatment for his or her medical/surgical claims. It is enough
for such a plaintiff to allege the existence of a procedure used
in assessing MH/SUD benefit claims that is more restrictive
than those used in assessing medical/surgical claims under
the same classification, as long as the allegation is
adequately pled. By alleging a systematic denial of those
MH/SUD benefit claims and citing a California state agency
report concluding that certain UnitedHealthcare entities
4            RYAN S. V. UNITEDHEALTH GROUP, INC.

were applying a more stringent review process to such
claims, Ryan S. plausibly alleges that UnitedHealthcare was
applying an improper internal process in violation of the
Parity Act.
   Citing ERISA language suggesting that a violation of 29
U.S.C. § 1185a is a breach of fiduciary duty, the panel
concluded that Ryan S. also alleged a breach of fiduciary
duty.
    The panel therefore reversed the dismissal of Ryan S.’s
claims based on the Parity Act and for breach of fiduciary
duty. As Ryan S. failed to identify any specific plan terms
that the alleged practices would violate, the panel affirmed
the dismissal of his claims based on a violation of the terms
of his plan.

                        COUNSEL

Elizabeth Hopkins (argued) and Lisa S. Kantor, Kantor &
Kantor LLP, Northridge, California; Richard T. Collins and
Damon D. Eisenbrey, Arnall Golden Gregory LLP,
Washington, D.C.; for Plaintiff-Appellant.
April N. Ross (argued), Crowell & Moring LLP,
Washington, D.C.; Jennifer S. Romano, Andrew Holmer,
and Kenneth R. Taketa, Crowell & Moring LLP, Los
Angeles, California; Mana E. Lombardo, Lombardo Law
PC, Encino, California; for Defendants-Appellees.
             RYAN S. V. UNITEDHEALTH GROUP INC.           5

                        OPINION

CLIFTON, Circuit Judge:

    Plaintiff-Appellant Ryan S. brought a putative class
action under the Employee Retirement Income Security Act
of 1974 (“ERISA”) against UnitedHealth Group, Inc. and its
subsidiaries (collectively “UnitedHealthcare”). He alleges
that UnitedHealthcare applies a more stringent review
process to benefits claims for outpatient, out-of-network
mental health and substance use disorder (“MH/SUD”)
treatment than to otherwise comparable medical/surgical
treatment. Ryan S. asserts that by doing so,
UnitedHealthcare has violated the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act of
2008 (“Parity Act”), 29 U.S.C. § 1185a, in the process also
breaching its fiduciary duty and violating the terms of his
plan.
    UnitedHealthcare moved to dismiss under Federal Rule
of Civil Procedure 12(b)(6). The district court granted the
motion, concluding that all of Ryan S.’s claims were
insufficient as a matter of law. It based the dismissal
primarily on its conclusions that Ryan S. had (1) failed to
allege that his claims had been “categorically” denied and
(2) insufficiently identified analogous medical/surgical
claims that he had personally submitted and
UnitedHealthcare had processed more favorably.
    We conclude that Ryan S. adequately stated a claim for
a violation of the Parity Act. An ERISA plan can violate the
Parity Act in different ways: it can explicitly exclude some
form of treatment for MH/SUD issues that is offered for
comparable medical/surgical issues; it can apply a facially
neutral plan term in an unequal way between MH/SUD and
6            RYAN S. V. UNITEDHEALTH GROUP, INC.

medical/surgical benefits; or it can apply a more stringent
internal process to MH/SUD claims than to medical/surgical
claims. In this case, Ryan S. alleges a violation of the third
type, claiming that UnitedHealthcare applied a more
restrictive review process to his outpatient, out-of-network
MH/SUD claims. A plaintiff presenting that type of
contention may be able to allege a plausible claim without
having to allege a categorical practice or differential
treatment for his or her medical/surgical claims. It is enough
for such a plaintiff to allege the existence of a procedure used
in assessing MH/SUD benefit claims that is more restrictive
than those used in assessing medical/surgical claims under
the same classification, as long as the allegation is
adequately pled.
    By alleging a systematic denial of those MH/SUD
benefit claims and citing a California state agency report that
had concluded that certain UnitedHealthcare entities,
including Defendant UnitedHealthcare of California
(“UHC”), were applying a more stringent review process to
such claims, Ryan S. plausibly alleges that UnitedHealthcare
was applying an improper internal process in violation of the
Parity Act. The allegations might ultimately not be proven,
but they are sufficient at the pleading stage.
    We reverse the dismissal of Ryan S.’s claims based on
the Parity Act and for breach of fiduciary duty. As Ryan S.
fails to identify any specific plan terms that the alleged
practices would violate, we affirm the dismissal of his claims
based on a violation of the terms of his plan. We thus reverse
the judgment in part, affirm it in part, and remand the matter
for further proceedings.
             RYAN S. V. UNITEDHEALTH GROUP INC.           7

I. Background
    Ryan S. is a California resident and a beneficiary of an
ERISA group health plan insured, managed, and
administered by UnitedHealthcare. Ryan S.’s plan covers
outpatient, out-of-network MH/SUD treatment at 70% of
covered charges, and 100% once the out-of-pocket
maximum is met. Over the course of many months between
2017 and 2019, Ryan S. completed two different outpatient,
out-of-network substance use disorder programs.
UnitedHealthcare did not cover most of the costs of the
programs. Ryan S. was variously informed that his claims
were denied because “your plan does not cover the services
you received,” “no documentation was submitted,” and “the
information submitted does not contain sufficient detail.”
Overall, Ryan S. was left personally responsible for
hundreds of thousands of dollars in charges.
    Ryan S. filed a putative class action against
UnitedHealth Group, Inc. and eight of its wholly owned
subsidiaries on July 11, 2019. That complaint was
subsequently amended. The operative Third Amended
Complaint (“TAC”) alleges that UnitedHealthcare violated
three of ERISA’s requirements: (1) the Parity Act, codified
at 29 U.S.C. § 1185a; (2) the fiduciary duty of loyalty,
described in 29 U.S.C. § 1104; and (3) the requirement
under § 1104 to follow the contractual terms of a
beneficiary’s plan. The TAC seeks various forms of relief on
behalf of the putative class, including a declaration that
UnitedHealthcare’s practices violated ERISA, an injunction
requiring Defendants to re-evaluate all claims for substance
use disorder and related laboratory services, and
disgorgement of profits.
8             RYAN S. V. UNITEDHEALTH GROUP, INC.

    In support of these allegations, the TAC does not rely
solely on Ryan S.’s personal experiences with denied claims.
It also cites a 2018 report by the California Department of
Managed Health Care, which concluded that Defendant
UHC violated the Parity Act by imposing a more stringent
review process on MH/SUD treatment claims. 1 The report
based this conclusion on the existence of an algorithm,
applied solely to MH/SUD treatment programs, which
assessed patients’ progress and referred cases for additional
review, leading to the potential denial of benefits if results
were deemed insufficient.
    The district court initially dismissed the TAC under Rule
12(b)(1) for lack of standing. On appeal, our court held that
Ryan S. had standing to pursue claims based on three alleged
practices: (1) refusing to cover outpatient MH/SUD
treatment, (2) refusing to pay for certain “auxiliary
treatments,” and (3) refusing to cover clinical laboratory
claims for MH/SUD patients. Ryan S. v. UnitedHealth Grp.,
Inc., 2022 WL 883743, at *2-4 (9th Cir. 2022). On remand,
UnitedHealthcare renewed its motion to dismiss under Rule
12(b)(6) for failure to state a claim. The district court granted
the motion, and this appeal followed.
II. Discussion
    We review de novo the grant of a motion to dismiss
under Rule 12(b)(6). Mudpie, Inc. v. Travelers Cas. Ins. Co.
of Am., 15 F.4th 885, 889 (9th Cir. 2021). A court conducting

1
 CAL. DEP’T MANAGED HEALTH CARE, OFF. PLAN MONITORING, FINAL
REPORT: FOCUSED SURVEY OF MENTAL HEALTH PARITY AND
ADDICTION EQUITY ACT (MHPAEA) IMPLEMENTATION 15-16 (July 18,
2018)            [hereinafter          FINAL           REPORT],
https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/1
26_r_MHPAEA_071818.pdf (last visited Feb. 6, 2024).
                RYAN S. V. UNITEDHEALTH GROUP INC.                       9

such an inquiry “accept[s] the factual allegations of the
complaint as true and construe[s] them in the light most
favorable to the plaintiff.” Id. (citation omitted). The motion
should be denied if the claim is plausible on its face, that is,
if “the plaintiff pleads factual content that allows the court
to draw the reasonable inference that the defendant is liable
for the misconduct alleged.” Ashcroft v. Iqbal, 556 U.S. 662,
678 (2009) (citing Bell Atl. Corp. v. Twombly, 550 U.S. 544,
556 (2007)).
    Ryan S. alleges that UnitedHealthcare maintains a
system that subjects MH/SUD treatment claims to a more
stringent review process than other medical/surgical claims.
He argues that this practice violates three of the duties that
ERISA imposes on administrators: (1) the requirement that
administrators treat MH/SUD and medical/surgical claims
equally, (2) the fiduciary duty of loyalty, and (3) the mandate
to follow all plan terms. Based on each of these three alleged
violations, Ryan S. seeks relief under 29 U.S.C.
§ 1132(a)(3), which allows a plaintiff to bring a claim based
on “any act or practice which violates” ERISA. 2

2
  The Supreme Court has described Section 1132(a)(3) as a “catchall”
designed to “act as a safety net, offering appropriate equitable relief for
injuries caused by violations that [Section 1132] does not elsewhere
adequately remedy.” Varity Corp. v. Howe, 516 U.S. 489, 512 (1996).
While conceding that the question is not yet before us, UnitedHealthcare
asserts that “reprocessing of claims[] cannot be granted . . . under 29
U.S.C. § 1132(a)(3) as a matter of law.” It bases this assertion on our
recent decision in Wit v. United Behav. Health, 79 F.4th 1068 (9th Cir.
2023), where we held that “the district court erred in concluding that
reprocessing was an available remedy under 29 U.S.C. § 1132(a)(3).” Id.
at 1086. However, UnitedHealthcare overstates the breadth of that
decision. In Wit, class certification was improper “[b]ecause the classes
10             RYAN S. V. UNITEDHEALTH GROUP, INC.

     A. Parity Act
    The Parity Act requires that any limitations on “mental
health or substance use disorder benefits” in an ERISA plan
be “no more restrictive than the predominant treatment
limitations applied to substantially all [covered] medical and
surgical benefits.” 29 U.S.C. § 1185(a)(3)(A)(ii). Thus, to
succeed on a claim under the Parity Act, a plaintiff must
show that an ERISA plan that offers both medical/surgical
benefits and MH/SUD benefits imposed a “more restrictive
limitation on [MH/SUD] treatment than limitations on
treatment for medical and surgical issues.” Stone v.
UnitedHealthcare Ins. Co., 979 F.3d 770, 774 (9th Cir.
2020). The district court held that Ryan S. did not plausibly
allege the existence of such a limitation. We disagree.
     We appreciate the challenge posed here for the district
court. We have previously noted that although the Parity
Act’s “language is quite clear,” it has “left some room for
uncertainty or ambiguity regarding its application to specific
ERISA plan terms and situations.” Danny P. v. Catholic
Health Initiatives, 891 F.3d 1155, 1158 (9th Cir. 2018)
(citing 29 U.S.C. § 1185a(a)(3)(A)). The guidance provided
by our court or other circuit courts is limited. As the district

were not limited to those claimants whose claims were denied based only
on the challenged [process] . . . .” Id. The plaintiffs attempted to use
Section 1132(a)(3) to circumvent that conclusion, arguing that
reprocessing could still be an equitable remedy for class members who
had not been affected by the challenged process. Id. We rejected that
argument, holding that reprocessing was not available in equity for class
members for whom the challenged process was “unrelated to Plaintiffs’
claim for benefits.” Id. (emphasis added). Should this case proceed to
class certification, reprocessing could still be an appropriate equitable
remedy for any individuals whose claims were denied because
UnitedHealthcare applied the challenged review process.
              RYAN S. V. UNITEDHEALTH GROUP INC.             11

court noted, one ambiguity concerns “how to state a claim
for a Parity Act violation,” on which “[t]here is no clear
law.” Patrick S. v. United Behavioral Health, 516 F. Supp.
3d 1303, 1306 (D. Utah 2021) (emphasis added).
    Without clear guidance, district courts have improvised
when crafting pleading standards, often with inconsistent
results. Compare Michael W. v. United Behav. Health, 420
F. Supp. 3d 1207, 1235 (D. Utah 2019), with Welp v. Cigna
Health & Life Ins. Co., 2017 WL 3263138, at *5-6 (S.D. Fla.
2017). These inconsistencies result from the fact that the
language of the Parity Act is broad enough to contemplate
multiple types of claims. Plaintiffs can allege that an ERISA
plan contains an exclusion that is discriminatory on its face,
that the plan contains a facially neutral term that is
discriminatorily applied to MH/SUD treatment, or that the
plan administrator applies an improper internal process that
results in the exclusion of some MH/SUD treatment.
Michael W., 420 F. Supp. 3d at 1235-36. These three types
of cases can be referred to respectively as (1) facial exclusion
cases, (2) as-applied cases, and (3) internal process cases.
Attempts to craft and apply a rigid multi-prong test that
applies to all three situations can lead to the erroneous
dismissal of potentially meritorious Parity Act claims.
    The last type of case is at issue here. As this court stated
in our previous decision in this case: “The thrust of Ryan S.’s
lawsuit is that United [Healthcare] handles claims for
treatment of substance use disorder differently than it
handles treatment for other claims.” Ryan S., 2022 WL
883743, at *3; see id. at *4 (Collins, J., dissenting in part)
(“[Ryan S.’s] complaint rests on the distinct theory that
Defendants adopted certain general ‘practices’ for handling
particular types of claims that were not consistent
with . . . ERISA’s ‘parity provisions.’”). Ryan S. does not
12            RYAN S. V. UNITEDHEALTH GROUP, INC.

allege any express exclusions in his plan, nor identify
specific terms that, as applied, led to the denial of his claims.
Instead, he alleges that UnitedHealthcare uses improper
internal processes in determining whether outpatient, out-of-
network MH/SUD treatment is covered under the plan. See
29 C.F.R. § 2590.712(c)(4)(i) (“processes, strategies,
evidentiary standards, or other factors” may not be applied
in a discriminatory manner); cf. Bushell v. UnitedHealth
Grp. Inc., 2018 WL 1578167, at *5 (S.D.N.Y. 2018). This
case thus presents the question of what pleading standard
applies to cases alleging an improper internal process.
    In assessing that question for any category of Parity Act
claims, we must keep certain principles in mind. Because
violations of the Parity Act can take different forms, an
evaluation of the plausibility of a complaint must reflect the
specific violation alleged. For instance, Ryan S. did not need
to allege a “categorical” practice or the uniform denial of his
benefits, as the district court appeared to require. We
previously held that because Ryan S.’s claims are based on
the existence of an internal process, he “need not necessarily
prove that any practice was categorical.” Ryan S., 2022 WL
883743, at *3; see also A.Z. by & through E.Z. v. Regence
Blueshield, 333 F. Supp. 3d 1069, 1082 (W.D. Wash. 2018).
Handling MH/SUD treatment claims more stringently
violates the Parity Act regardless of whether such
differential treatment leads to the uniform denial of all
claims.
    In addition, a plaintiff need not identify an analogous
category of claims with precision. While a plaintiff alleging
a Parity Act violation must give reason to believe that some
analogous category of claims is treated differently, the
plaintiff can define that analogous category quite broadly.
The statute and its implementing regulations require only a
             RYAN S. V. UNITEDHEALTH GROUP INC.           13

comparison between the MH/SUD treatment at issue and
other treatment within the same “classification”—in this
case, outpatient, out-of-network treatment. See 29 U.S.C.
§ 1185a(a)(8)(A)(iv);      see     also     29     C.F.R.
§ 2590.712(c)(2)(ii)(A) (enumerating the six different
classifications of benefits). Any other medical/surgical
treatment within that classification can be a sufficient
comparator.
    A plaintiff alleging an improper internal process also
need not specify the different process that allegedly applies
to the analogous category of medical/surgical benefits.
Plaintiffs who have not received medical/surgical treatment
in the same classification as their MH/SUD treatment would
have no basis to determine the process used for those
analogous claims. See Bushell, 2018 WL 1578167, at *6 (“If
the Court required Bushell’s complaint to specify the exact
process by which United reached its decision on anorexia
cases and the exact process it employed for diabetes
treatment, it would likely create a serious obstacle to
meritorious Parity Act claims.”); Melissa P. v. Aetna Life
Ins. Co., 2018 WL 6788521, at *3 (D. Utah 2018) (“To
require more would prevent any plaintiff from bringing a
mental health parity claim based on disparate operation
unless she had . . . personal experience with both
standards.”); see Vorpahl v. Harvard Pilgrim Health Ins.
Co., 2018 WL 3518511, at *3 (D. Mass. 2018) (“[T]he
process and factors by which [a] nonquantitative treatment
limitation could even be applied both to mental health
benefits and medical/surgical benefits . . . need[] to be
resolved as the case proceeds after the benefit of
discovery.”). A plaintiff must merely allege facts sufficient
to suggest that the challenged process is specific to MH/SUD
claims in order to meet the plausibility pleading standard.
14           RYAN S. V. UNITEDHEALTH GROUP, INC.

    Overall, that standard requires a plaintiff bringing an
internal process case to plausibly allege the existence of a
procedure used in assessing MH/SUD benefit claims that is
more restrictive than those used in assessing some other
claims under the same classification. Cf. Twombly, 550 U.S.
at 557 (holding that allegations of conduct that are merely
consistent with wrongdoing do not state a claim unless
“placed in a context that raises a suggestion of” such
wrongdoing). A plaintiff advancing an internal process
challenge needs to provide some reason to believe that the
denial of MH/SUD claims was impacted by a process that
does not apply to medical/surgical claims.
      Simply alleging the denial of a plaintiff’s claims for
behavioral health benefits is unlikely by itself to support a
plausible inference that a defendant employed policies in
violation of the Parity Act. See H.H. v. Aetna Ins. Co., 342
F. Supp. 3d 1311, 1320-21 (S.D. Fla. 2018) (“While
. . . Plaintiffs need not have proof of the specific processes
that [the defendant] allegedly uses to deny coverage . . . ,
Plaintiffs must still include some factual allegations to lend
support to their claim.”).
    In this case, Ryan S. pleads something more. Beyond his
own denied claims, he cites the 2018 report by the California
Department of Managed Healthcare, described above. That
report concluded that UHC processed MH/SUD claims
differently. According to the report, claims submitted to
UHC for outpatient MH/SUD treatment are evaluated using
a process called Algorithms for Effective Reporting and
Treatment (ALERT). FINAL REPORT at 15-16. The
algorithms identify how often an enrollee is receiving
outpatient, out-of-network treatment and whether the
enrollee is making progress in the program. If the algorithms
determine that certain criteria are not being met, “the case
               RYAN S. V. UNITEDHEALTH GROUP INC.                    15

[is] referred for peer review . . . which could result in a
denial of services.” Id. at 15. Meanwhile, UHC staff told the
agency that no comparable additional review process applies
to members undergoing outpatient medical/surgical
treatment. Id. at 16. The state agency therefore determined
that the “approval process for outpatient MH/SUD services
is not comparable and that [utilization management] review
is being applied in a more stringent manner for outpatient
MH/SUD services.” Id.
    The use of an algorithmic process to trigger additional
levels of review could explain why Ryan S.’s claims were
not denied for a single stated reason. If the ALERT system
triggers a more intensive review process for MH/SUD
claims, reviewing staff might subsequently deny each
individual claim for any number of reasons. Even if all those
denials were independently valid, the mere fact that the
reasons to deny coverage were identified only because the
MH/SUD claims were subjected to an additional layer of
scrutiny could violate the Parity Act.
    UnitedHealthcare asserts that the report’s findings have
an insufficient nexus to Ryan S.’s claims, as he relies on the
inference that such practices could explain his experiences
with UnitedHealthcare. 3 Such an inference is not
unwarranted on a motion to dismiss, however, where the
court must construe all allegations in the light most favorable

3
 UnitedHealthcare also characterizes ALERT as relevant only to the pre-
authorization process, which it argues Ryan S. does not have standing to
challenge. However, as described above, the agency report’s findings
were not so limited. The report suggests that UHC uses ALERT
throughout the process of a beneficiary’s MH/SUD outpatient treatment,
and that ALERT can lead to the denial of a benefits claim at any point.
FINAL REPORT at 15-16. The conclusions regarding ALERT pertain to
claims which Ryan S. has standing to bring.
16           RYAN S. V. UNITEDHEALTH GROUP, INC.

to the plaintiff. The report was the result of a government
investigation conducted concurrently with the benefit
denials that form the basis of Ryan S.’s claims. The report
suggests that, at least at the time, UnitedHealthcare subjected
all MH/SUD outpatient claims to a more restrictive review
process. That is enough to connect the report’s findings to
Ryan S.’s denial of benefits and is therefore sufficient to
place Ryan S.’s allegations “in a context that raises a
suggestion of” wrongdoing. Twombly, 550 U.S. at 557.
    The report is much more thorough than any pre-lawsuit
investigation that a typical Parity Act plaintiff could be
expected to conduct on his or her own. It directly analyzes
UnitedHealthcare’s review process for MH/SUD claims and
compares it to the plan’s review process for other claims in
the same classification. A pleading standard under which
such a comprehensive investigation is insufficient would
make it inordinately difficult for a plaintiff to challenge an
internal process, given the likelihood that an individual
claimant’s own administrative record would not shed light
on the internal processes to which the claims were subjected.
The plausibility pleading standard is not that unreachable. In
short, Ryan S.’s allegations, in conjunction with the agency
report, are more than sufficient to allege a plausible violation
of the Parity Act.
     B. Breach of Fiduciary Duty
    The district court primarily rejected Ryan S.’s breach of
fiduciary duty claims for the same reasons that it dismissed
his Parity Act claim: a failure to allege the existence of a
violative practice. As we conclude that Ryan S. sufficiently
alleged that UnitedHealthcare implemented a more stringent
process for determining MH/SUD benefit claims in violation
of the Parity Act, we conclude he also alleged a breach of
               RYAN S. V. UNITEDHEALTH GROUP INC.                    17

fiduciary duty. 4 ERISA specifies that fiduciaries must
discharge their duties solely in the interests of plan
beneficiaries and participants “in accordance with the
documents and instruments governing the plan insofar as
such documents and instruments are consistent with the
provisions of” ERISA. 29 U.S.C. § 1104(a)(1)(D) (emphasis
added). This language suggests that a violation of 29 U.S.C.
§ 1185a is a breach of fiduciary duty. See, e.g., Doe v. United
Behav. Health, 523 F. Supp. 3d 1119, 1127 (N.D. Cal. 2021)
(denying defendant’s motion for summary judgment in a
breach of fiduciary duty suit predicated on a violation of the
Parity Act).
    C. Violation of Plan Terms
    A plaintiff bringing a claim based on a violation of plan
terms “must identify a specific plan term that confers the
benefit in question.” Steelman v. Prudential Ins. Co. of Am.,
2007 WL 1080656, at *7 (E.D. Cal. 2007) (quoting Stewart
v. Nat’l Educ. Ass’n, 404 F. Supp. 2d 122, 130 (D.D.C.
2005)). Even though Ryan S. has plausibly alleged the
existence of a more stringent review process for MH/SUD
claims, such a process would not automatically violate the
terms of his plan. To succeed on this claim, Ryan S. must
identify a term of his plan that Defendants violated, such as
a term that promised an identical review process for all
claims.

4
  UnitedHealthcare argues that if any of Ryan S.’s claims proceed, they
should do so against only United Behavioral Health, Inc., as Ryan S. has
not adequately alleged that any other defendant was a fiduciary. The
district court has not addressed this question, and it seems to us
premature to do so at this point in the proceedings. Further, the agency
report indicated that at least UHC had direct involvement in the
implementation of the ALERT system. FINAL REPORT at 16.
18            RYAN S. V. UNITEDHEALTH GROUP, INC.

    As the district court concluded, Ryan S. has not done so.
Instead, he rests on the assertion that “it is hard to fathom
how Defendants’ failure to decide many of Ryan’s claims
could possibly be consistent with Plan terms requiring
UnitedHealthcare to decide and pay claims for medically
necessary substance use disorder treatment.” The question is
not whether it is “hard to fathom” that a plan did not include
a specific requirement, but whether the plan actually
included such a requirement that Defendants then violated.
Ryan S. fails to make such a showing.
III. Conclusion
    We affirm the district court’s dismissal of Ryan S.’s
claims based on a violation of the terms of his plan. We
reverse the district court’s dismissal of Ryan S.’s claims for
violation of the Parity Act and breach of fiduciary duty, and
we remand for further proceedings consistent with this
opinion.
     Each party shall bear its own costs on appeal.
AFFIRMED in part; REVERSED in part; REMANDED
for further proceedings.