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Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 1 of 10
`
`DATE FILED: June 18, 2021 11:41 AM
`FILING ID: 610539783BCD9
`
`CASE NUMBER: 2021CV31940
`
`DISTRICT COURT, COUNTY OF DENVER, STATE
`OF COLORADO
`1437 Bannock Street, Room 256
`Denver, Colorado 80202
`Plaintiff: JANET ROUCIS
`
`v.
`
`Defendants: CIGNA HEALTH MANAGEMENT,
`INC. and CIGNA HEALTH AND LIFE
`INSURANCE COMPANY
`
`(cid:0) COURT USE ONLY (cid:0)
`
`Attorneys for Plaintiff:
`
`Elizabeth Hart, CO Reg. #46041
`Melissa A. Hailey, CO Reg. #42836
`Hailey | Hart PLLC
`383 Corona Street, Suite 319
`Denver, CO 80218
`Telephone: 720-400-7970
`liz@haileyhartlaw.com
`melissa@haileyhartlaw.com
`
`Case No.:
`
`Div:
`
`COMPLAINT AND JURY DEMAND
`
`This is an action for breach of contract, first-party bad faith, and violation of C.R.S. §§ 10-
`
`3-1115 and -1116 arising from Defendants’ unreasonable refusal to cover the cost of Plaintiff’s
`
`medically necessary brain surgery. The insured, Plaintiff Janet Roucis (“Roucis”), by and through
`
`her attorneys, Hailey | Hart PLLC, hereby submits her Complaint and Jury Demand against the
`
`insurers, Defendant CIGNA Health Management, Inc. and Defendant CIGNA Health and Life
`
`Insurance Company (collectively, “Cigna”) as follows:
`
`PARTIES, JURISDICTION & VENUE
`
`1.
`
`Roucis is an individual who, at all times relevant, resided in the State of Colorado.
`1
`
`EXHIBIT A
`
`

`

`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 2 of 10
`
`2.
`
`Defendant CIGNA Health Management, Inc. is a foreign corporation with its
`
`principal place of business at 1601 Chestnut Street, Philadelphia, Pennsylvania 19192. CIGNA
`
`Health Management, Inc. is authorized to conduct business in the State of Colorado and did, at all
`
`times relevant, engage in the business of insurance in the State of Colorado. Upon information
`
`and belief, one or more employees of CIGNA Health Management, Inc. handled the claim for
`
`health insurance benefits relevant to the allegations in this Complaint.
`
`3.
`
`Defendant CIGNA Health and Life Insurance Company is a foreign corporation
`
`with its principal place of business at 900 Cottage Grove Road, Hartford, Connecticut 06152.
`
`CIGNA Health and Life Insurance Company is authorized to conduct business in the State of
`
`Colorado and did, at all times relevant, engage in the business of insurance in the State of Colorado.
`
`Upon information and belief, CIGNA Health and Life Insurance Company wrote the policy for
`
`health insurance relevant to the allegations in this Complaint. Upon information and belief, one
`
`or more employees of CIGNA Health and Life Insurance Company handled the claim for health
`
`insurance benefits relevant to the allegations in this Complaint.
`
`4.
`
`5.
`
`6.
`
`This Court has subject matter jurisdiction over this action.
`
`Venue is proper in the County of Denver pursuant C.R.C.P. 98(c).
`
`GENERAL ALLEGATIONS
`
`In approximately November 2019, Roucis utilized the services of an insurance
`
`broker to apply for health insurance coverage with Cigna.
`
`7.
`
`Cigna approved Roucis’ application and thereafter issued to her an enforceable
`
`policy of individual health insurance (“the Policy”).
`
`
`
`2
`
`

`

`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 3 of 10
`
`8.
`
`The Policy is not governed by the Employee Retirement Income Security Act of
`
`1974 (“ERISA”), 29 U.S.C. 1001, et seq.
`
`9.
`
`Subject to relevant terms and conditions, the Policy obligates Cigna to cover
`
`services and supplies that are “medically necessary.”
`
`10.
`
`Upon information and belief, “medically necessary” services are those that are:
`
`a.
`
`b.
`
`c.
`
`d.
`
`e.
`
`f.
`
`appropriate and necessary for the symptoms, diagnosis, or treatment of the
`
`medical or dental condition;
`
`clinically appropriate in terms of type, frequency, extent, site, and duration;
`
`provided for the diagnosis or direct care and treatment of the medical or
`
`dental condition;
`
`within generally accepted standards of good medical practice within the
`
`community of qualified professionals;
`
`not primarily for the convenience of any Insured Person, Physician, or
`
`another Provider;
`
`rendered in the least intensive setting that is appropriate for the delivery of
`
`the services and supplies; and
`
`g.
`
`the most appropriate procedure, supply, equipment, or service, which can
`
`be safely provided and that satisfies the following the requirements:
`
`i.
`
`must have been proven by scientific studies published in peer-
`
`reviewed medical literature to be associated with beneficial health
`
`outcomes, demonstrating that the expected health benefits are
`
`clinically significant and produce a greater likelihood of benefits,
`
`
`
`3
`
`

`

`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 4 of 10
`
`without a disproportionately greater risk of harm or complications,
`
`for the patient with the particular medical condition being treated
`
`than other possible alternatives; and
`
`ii.
`
`generally accepted forms of treatment that are less invasive have
`
`been tried and found to be ineffective or otherwise unsuitable; and
`
`iii.
`
`for Hospital stays, acute care as an inpatient is necessary due to the
`
`kind of services the patient is receiving or the severity of the medical
`
`condition, and that safe and adequate care cannot be received as an
`
`outpatient or in a less intensified medical setting.
`
`
`
`
`
`11. According to Cigna’s policies and guidelines, stent placement for idiopathic
`
`intracranial hypertension (“IIH”) may be considered medically necessary.
`
`12.
`
`At all times relevant, Roucis paid all monthly premiums to Cigna and/or otherwise
`
`materially complied with her obligations under the Policy.
`
`13.
`
`On August 22, 2020, Roucis experienced a medical event in her inner ear, which
`
`caused immediate bilateral ear pain, sudden hearing loss, and a severe decline in her quality of life.
`
`14.
`
`Following this medical event, Roucis experienced waves of excruciating and
`
`debilitating head and jaw pain due to intercranial pressure and tinnitus.
`
`15.
`
`16.
`
`Roucis was referred to Ian Kaminsky, M.D. (“Kaminsky”) for medical treatment.
`
`Kaminsky is a neurointerventional surgeon practicing at RIA Neurovascular in
`
`Englewood, Colorado, board-certified in both diagnostic radiology and neuroradiology.
`
`17.
`
`On December 18, 2020, Kaminsky performed a diagnostic cerebral angiogram,
`
`including a four-vessel diagnostic angiogram and venography with pressure measurements. As a
`
`
`
`4
`
`

`

`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 5 of 10
`
`result of this diagnostic procedure, Kaminsky diagnosed Roucis with idiopathic intracranial
`
`hypertension, secondary to right transverse sinus stenosis. As a result of this diagnostic procedure,
`
`Kaminsky concluded the transcatheter placement of an intravascular stent (“the Surgery”) was
`
`both urgent and necessary to address Roucis’ condition and alleviate Roucis’ associated symptoms.
`
`18.
`
`Upon information and belief, the Policy required that Roucis obtain pre-
`
`authorization for the Surgery to secure coverage and receive associated health insurance benefits.
`
`19.
`
`20.
`
`Roucis sought pre-authorization for the Surgery from Cigna.
`
`On December 24, 2020, Cigna denied Roucis’ request for pre-authorization, stating
`
`the Surgery was not “medically necessary,” and thus not covered by the Policy.
`
`21.
`
`Roucis disagreed with Cigna’s decision and requested an expedited appeal due to
`
`the severity of her symptoms her urgent need for treatment.
`
`22.
`
`In support of Roucis’ appeal, Kaminsky sent to Cigna a detailed report regarding
`
`the medical necessity of the Surgery. Such report included a description of Roucis’ relevant
`
`medical history and diagnosis, as well as Kaminsky’s treatment rationale. Such report was
`
`accompanied by medical literature supporting the medical necessity of the Surgery. Such report
`
`put Cigna on notice that Roucis was in excruciating pain, had suffered a precipitous decline in her
`
`quality of life, and was contemplating suicide due to the severity of her symptoms.
`
`23.
`
`24.
`
`On January 2, 2021, Cigna notified Roucis it would not expedite her appeal.
`
`On January 4, 2021, Cigna notified Roucis that an Appeals Committee would
`
`review her case on January 27, 2021 at 11:00 AM.
`
`
`
`5
`
`

`

`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 6 of 10
`
`25.
`
`The Cigna Appeals Committee consisted of Douglas Leavengood, M.D. (Medical
`
`Principal), Yvonne Moore, RN (Nurse Case Management Lead Analyst), and Sonya Covington
`
`(Non-clinician Appeals Processing Senior Representative).
`
`26.
`
`Kaminsky and Roucis both attended the January 27th meeting by telephone. During
`
`that call, Kaminsky again told Cigna how and why the Surgery was medically necessary.
`
`27.
`
`On January 28, 2021, Cigna again denied Roucis’ request for pre-authorization,
`
`stating again that the Surgery was not “medically necessary.”
`
`28.
`
`On February 11, 2021, Kaminsky performed the Surgery on Roucis at Swedish
`
`Medical Center.
`
`29.
`
`30.
`
`Roucis paid out-of-pocket for the Surgery.
`
`As a result of the Surgery, Roucis has experienced significant relief from the
`
`symptoms described herein at ¶¶ 12, 13, and 22.
`
`31.
`
`The Surgery was a “medically necessary” procedure to redress the symptoms
`
`associated with IIH, secondary to right transverse sinus stenosis.
`
`32.
`
`33.
`
`The Surgery was accordingly covered by the terms of the Policy.
`
`There is no rational justification for Cigna’s refusal to authorize the Surgery,
`
`expedite Roucis’ appeal, and/or cover the cost of the Surgery under the Policy.
`
`34.
`
`As a direct and proximate result of Cigna’s refusal to authorize the Surgery,
`
`expedite Roucis’ appeal, and cover the cost of the Surgery under the Policy, Roucis has suffered
`
`damages, injuries, and losses.
`
`FIRST CLAIM FOR RELIEF
`(Breach of Contract)
`
`
`6
`
`
`
`

`

`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 7 of 10
`
`35.
`
`Roucis incorporates by reference the allegations set forth with specificity in ¶¶ 1-
`
`33 of this Complaint as if fully set forth herein.
`
`36.
`
`The Policy is and was, at all times relevant, a valid and enforceable contract for
`
`insurance.
`
`37.
`
`Cigna breached the terms of the Policy by denying authorization for the Surgery
`
`and refusing to cover the cost of the Surgery.
`
`38.
`
`At all times relevant, Roucis met or substantially complied with her duties under
`
`the Policy.
`
`39.
`
`As a direct and proximate result of Cigna’s breach of contract, Roucis has suffered
`
`injuries, damages, and losses in an amount to be proven at trial.
`
`SECOND CLAIM FOR RELIEF
`(First-Party Bad Faith)
`
`Roucis incorporates by reference the allegations set forth with specificity in ¶¶ 1-
`
`40.
`
`39 of this Complaint as if fully set forth.
`
`41.
`
`As her health insurer, Cigna owed to Roucis certain duties in accordance with the
`
`implied covenant of good faith and fair dealing.
`
`42.
`
`Cigna breached its duty of good faith and fair dealing by engaging in, without
`
`limitation, the following unreasonable acts:
`
`
`
`
`
`
`
`
`
`a.
`
`b.
`
`c.
`
`d.
`
`failing to recognize the Surgery as a “medically necessary” procedure;
`
`failing to authorize the Surgery as a “medically necessary” procedure;
`
`failing to cover the Surgery as a “medically necessary” procedure;
`
`ignoring the opinions of Kaminsky regarding the urgency and medical
`
`necessity of the Surgery;
`
`
`
`7
`
`

`

`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 8 of 10
`
`
`
`e.
`
`ignoring the medical literature reasonably available and/or provided by
`
`Kaminsky regarding the medical necessity of the Surgery;
`
`f.
`
`failing to reasonably explain its rationale for denying pre-authorization for
`
`the Surgery;
`
`
`
`g.
`
`h.
`
`failing to expedite the appeal process;
`
`refusing to authorize the Surgery or cover the cost of the Surgery without
`
`conducting a reasonable investigation based on all available information;
`
`
`
`i.
`
`not attempting in good faith to effectuate a prompt, fair, and equitable
`
`settlement of Roucis’ claim for health insurance benefits;
`
`h.
`
`forcing Roucis to institute litigation to recover benefits owed under the
`
`Policy;
`
`
`
`f.
`
`failing to follow Cigna’s own internal policies on determining medical
`
`necessity; and
`
`
`
`g.
`
` engaging in other conduct prohibited by C.R.S. § 10-3-1104(1)(h).
`
`43.
`
`Cigna knew or recklessly disregarded the fact that its above-described conduct was
`
`unreasonable.
`
`44.
`
`Cigna recklessly disregarded the validity of Roucis’ request for pre-authorization
`
`and claim for benefits.
`
`45.
`
`As a direct and proximate result of Cigna’s bad faith conduct, Roucis has suffered
`
`injuries, damages, and losses in an amount to be proven at trial.
`
`THIRD CLAIM FOR RELIEF
` (Violation of C.R.S. §§ 10-3-1115 and -1116)
`
`
`
`
`8
`
`

`

`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 9 of 10
`
`
`
`46.
`
`Roucis incorporates by reference the allegations set forth with specificity in ¶¶ 1-
`
`45 of this Complaint as if fully set forth.
`
`
`
`47.
`
`C.R.S. §§ 10-3-1115 and -1116 forbid a person engaged in the business of
`
`insurance from unreasonably denying payment of a claim for benefits owed to or on behalf of
`
`any first-party claimant.
`
`
`
`48.
`
`49.
`
`50.
`
`Roucis is a first-party claimant under Section 10-3-1115(1)(b)(I) and the Policy.
`
`The Surgery was a covered procedure under the Policy.
`
`Cigna unreasonably denied the payment of insurance benefits owed under the
`
`Policy relating to the Surgery.
`
`51.
`
`52.
`
`53.
`
`
`
`There is no reasonable justification for Cigna’s denial of benefits owed.
`
`Cigna’s unreasonable denial violated C.R.S. §§ 10-3-1115 and -1116.
`
`As a direct and proximate result of Cigna’s statutory violation, Roucis has
`
`suffered injuries, damages, and losses in an amount to be proven at trial.
`
`
`
`54.
`
`Pursuant to C.R.S. § 10-3-1116, Roucis is entitled to recover reasonable
`
`attorneys’ fees, costs, and two times the covered benefit unreasonably denied by Cigna.
`
`PRAYER FOR RELIEF
`
`
`
`WHEREFORE, Roucis prays for a judgment in her favor and against Cigna for:
`
`(A)
`
`(B)
`
`economic damages equal to the amount of benefits owed under the Policy;
`
`non-economic damages to compensate her for the physical pain and suffering,
`
`financial stress, worry, and inconvenience caused by Cigna’s bad faith conduct;
`
`(C)
`
`(D)
`
`twice the covered benefit pursuant to C.R.S. § 10-3-1116;
`
`attorneys’ fees and costs pursuant to C.R.S. § 10-3-1116;
`
`
`
`9
`
`

`

`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 10 of 10
`
`(E)
`
`(F)
`
`pre- and post-judgment interest as allowed by law; and
`
`for such other and further relief as this Court deems just and proper.
`
`PLAINTIFF DEMANDS A TRIAL BY JURY ON ALL ISSUES SO TRIABLE.
`
`
`
`HAILEY | HART PLLC
`
`
`s/ Elizabeth A. Hart ______
`
`s/ Melissa A. Hailey
`
`Elizabeth A. Hart Esq. #46041
`Melissa A. Hailey Esq. #42836
`383 Corona Street
`Suite 319
`Denver, Colorado 80218
`720-400-7970
`liz@haileyhartlaw.com
`melissa@haileyhartlaw.com
`
`
`
`
`
`
`
`
`
`Respectfully submitted this 18th day of June, 2021.
`
`
`
`By:
`
`
`
`Plaintiff’s Address:
`1122 S. Flower Circle
`Lakewood, CO 80232
`
`
`
`10
`
`

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