`
`DATE FILED: June 18, 2021 11:41 AM
`FILING ID: 610539783BCD9
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`CASE NUMBER: 2021CV31940
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`DISTRICT COURT, COUNTY OF DENVER, STATE
`OF COLORADO
`1437 Bannock Street, Room 256
`Denver, Colorado 80202
`Plaintiff: JANET ROUCIS
`
`v.
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`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:
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`COMPLAINT AND JURY DEMAND
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`This is an action for breach of contract, first-party bad faith, and violation of C.R.S. §§ 10-
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`3-1115 and -1116 arising from Defendants’ unreasonable refusal to cover the cost of Plaintiff’s
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`medically necessary brain surgery. The insured, Plaintiff Janet Roucis (“Roucis”), by and through
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`her attorneys, Hailey | Hart PLLC, hereby submits her Complaint and Jury Demand against the
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`insurers, Defendant CIGNA Health Management, Inc. and Defendant CIGNA Health and Life
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`Insurance Company (collectively, “Cigna”) as follows:
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`PARTIES, JURISDICTION & VENUE
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`1.
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`Roucis is an individual who, at all times relevant, resided in the State of Colorado.
`1
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`EXHIBIT A
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`
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`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 2 of 10
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`2.
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`Defendant CIGNA Health Management, Inc. is a foreign corporation with its
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`principal place of business at 1601 Chestnut Street, Philadelphia, Pennsylvania 19192. CIGNA
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`Health Management, Inc. is authorized to conduct business in the State of Colorado and did, at all
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`times relevant, engage in the business of insurance in the State of Colorado. Upon information
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`and belief, one or more employees of CIGNA Health Management, Inc. handled the claim for
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`health insurance benefits relevant to the allegations in this Complaint.
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`3.
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`Defendant CIGNA Health and Life Insurance Company is a foreign corporation
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`with its principal place of business at 900 Cottage Grove Road, Hartford, Connecticut 06152.
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`CIGNA Health and Life Insurance Company is authorized to conduct business in the State of
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`Colorado and did, at all times relevant, engage in the business of insurance in the State of Colorado.
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`Upon information and belief, CIGNA Health and Life Insurance Company wrote the policy for
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`health insurance relevant to the allegations in this Complaint. Upon information and belief, one
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`or more employees of CIGNA Health and Life Insurance Company handled the claim for health
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`insurance benefits relevant to the allegations in this Complaint.
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`4.
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`5.
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`6.
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`This Court has subject matter jurisdiction over this action.
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`Venue is proper in the County of Denver pursuant C.R.C.P. 98(c).
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`GENERAL ALLEGATIONS
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`In approximately November 2019, Roucis utilized the services of an insurance
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`broker to apply for health insurance coverage with Cigna.
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`7.
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`Cigna approved Roucis’ application and thereafter issued to her an enforceable
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`policy of individual health insurance (“the Policy”).
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`
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`2
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`
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`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 3 of 10
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`8.
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`The Policy is not governed by the Employee Retirement Income Security Act of
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`1974 (“ERISA”), 29 U.S.C. 1001, et seq.
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`9.
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`Subject to relevant terms and conditions, the Policy obligates Cigna to cover
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`services and supplies that are “medically necessary.”
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`10.
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`Upon information and belief, “medically necessary” services are those that are:
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`a.
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`b.
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`c.
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`d.
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`e.
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`f.
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`appropriate and necessary for the symptoms, diagnosis, or treatment of the
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`medical or dental condition;
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`clinically appropriate in terms of type, frequency, extent, site, and duration;
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`provided for the diagnosis or direct care and treatment of the medical or
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`dental condition;
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`within generally accepted standards of good medical practice within the
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`community of qualified professionals;
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`not primarily for the convenience of any Insured Person, Physician, or
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`another Provider;
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`rendered in the least intensive setting that is appropriate for the delivery of
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`the services and supplies; and
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`g.
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`the most appropriate procedure, supply, equipment, or service, which can
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`be safely provided and that satisfies the following the requirements:
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`i.
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`must have been proven by scientific studies published in peer-
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`reviewed medical literature to be associated with beneficial health
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`outcomes, demonstrating that the expected health benefits are
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`clinically significant and produce a greater likelihood of benefits,
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`3
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`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 4 of 10
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`without a disproportionately greater risk of harm or complications,
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`for the patient with the particular medical condition being treated
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`than other possible alternatives; and
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`ii.
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`generally accepted forms of treatment that are less invasive have
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`been tried and found to be ineffective or otherwise unsuitable; and
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`iii.
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`for Hospital stays, acute care as an inpatient is necessary due to the
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`kind of services the patient is receiving or the severity of the medical
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`condition, and that safe and adequate care cannot be received as an
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`outpatient or in a less intensified medical setting.
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`11. According to Cigna’s policies and guidelines, stent placement for idiopathic
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`intracranial hypertension (“IIH”) may be considered medically necessary.
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`12.
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`At all times relevant, Roucis paid all monthly premiums to Cigna and/or otherwise
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`materially complied with her obligations under the Policy.
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`13.
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`On August 22, 2020, Roucis experienced a medical event in her inner ear, which
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`caused immediate bilateral ear pain, sudden hearing loss, and a severe decline in her quality of life.
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`14.
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`Following this medical event, Roucis experienced waves of excruciating and
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`debilitating head and jaw pain due to intercranial pressure and tinnitus.
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`15.
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`16.
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`Roucis was referred to Ian Kaminsky, M.D. (“Kaminsky”) for medical treatment.
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`Kaminsky is a neurointerventional surgeon practicing at RIA Neurovascular in
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`Englewood, Colorado, board-certified in both diagnostic radiology and neuroradiology.
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`17.
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`On December 18, 2020, Kaminsky performed a diagnostic cerebral angiogram,
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`including a four-vessel diagnostic angiogram and venography with pressure measurements. As a
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`4
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`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 5 of 10
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`result of this diagnostic procedure, Kaminsky diagnosed Roucis with idiopathic intracranial
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`hypertension, secondary to right transverse sinus stenosis. As a result of this diagnostic procedure,
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`Kaminsky concluded the transcatheter placement of an intravascular stent (“the Surgery”) was
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`both urgent and necessary to address Roucis’ condition and alleviate Roucis’ associated symptoms.
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`18.
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`Upon information and belief, the Policy required that Roucis obtain pre-
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`authorization for the Surgery to secure coverage and receive associated health insurance benefits.
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`19.
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`20.
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`Roucis sought pre-authorization for the Surgery from Cigna.
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`On December 24, 2020, Cigna denied Roucis’ request for pre-authorization, stating
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`the Surgery was not “medically necessary,” and thus not covered by the Policy.
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`21.
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`Roucis disagreed with Cigna’s decision and requested an expedited appeal due to
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`the severity of her symptoms her urgent need for treatment.
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`22.
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`In support of Roucis’ appeal, Kaminsky sent to Cigna a detailed report regarding
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`the medical necessity of the Surgery. Such report included a description of Roucis’ relevant
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`medical history and diagnosis, as well as Kaminsky’s treatment rationale. Such report was
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`accompanied by medical literature supporting the medical necessity of the Surgery. Such report
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`put Cigna on notice that Roucis was in excruciating pain, had suffered a precipitous decline in her
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`quality of life, and was contemplating suicide due to the severity of her symptoms.
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`23.
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`24.
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`On January 2, 2021, Cigna notified Roucis it would not expedite her appeal.
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`On January 4, 2021, Cigna notified Roucis that an Appeals Committee would
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`review her case on January 27, 2021 at 11:00 AM.
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`5
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`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 6 of 10
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`25.
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`The Cigna Appeals Committee consisted of Douglas Leavengood, M.D. (Medical
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`Principal), Yvonne Moore, RN (Nurse Case Management Lead Analyst), and Sonya Covington
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`(Non-clinician Appeals Processing Senior Representative).
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`26.
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`Kaminsky and Roucis both attended the January 27th meeting by telephone. During
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`that call, Kaminsky again told Cigna how and why the Surgery was medically necessary.
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`27.
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`On January 28, 2021, Cigna again denied Roucis’ request for pre-authorization,
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`stating again that the Surgery was not “medically necessary.”
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`28.
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`On February 11, 2021, Kaminsky performed the Surgery on Roucis at Swedish
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`Medical Center.
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`29.
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`30.
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`Roucis paid out-of-pocket for the Surgery.
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`As a result of the Surgery, Roucis has experienced significant relief from the
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`symptoms described herein at ¶¶ 12, 13, and 22.
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`31.
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`The Surgery was a “medically necessary” procedure to redress the symptoms
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`associated with IIH, secondary to right transverse sinus stenosis.
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`32.
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`33.
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`The Surgery was accordingly covered by the terms of the Policy.
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`There is no rational justification for Cigna’s refusal to authorize the Surgery,
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`expedite Roucis’ appeal, and/or cover the cost of the Surgery under the Policy.
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`34.
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`As a direct and proximate result of Cigna’s refusal to authorize the Surgery,
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`expedite Roucis’ appeal, and cover the cost of the Surgery under the Policy, Roucis has suffered
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`damages, injuries, and losses.
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`FIRST CLAIM FOR RELIEF
`(Breach of Contract)
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`6
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`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 7 of 10
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`35.
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`Roucis incorporates by reference the allegations set forth with specificity in ¶¶ 1-
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`33 of this Complaint as if fully set forth herein.
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`36.
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`The Policy is and was, at all times relevant, a valid and enforceable contract for
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`insurance.
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`37.
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`Cigna breached the terms of the Policy by denying authorization for the Surgery
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`and refusing to cover the cost of the Surgery.
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`38.
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`At all times relevant, Roucis met or substantially complied with her duties under
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`the Policy.
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`39.
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`As a direct and proximate result of Cigna’s breach of contract, Roucis has suffered
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`injuries, damages, and losses in an amount to be proven at trial.
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`SECOND CLAIM FOR RELIEF
`(First-Party Bad Faith)
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`Roucis incorporates by reference the allegations set forth with specificity in ¶¶ 1-
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`40.
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`39 of this Complaint as if fully set forth.
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`41.
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`As her health insurer, Cigna owed to Roucis certain duties in accordance with the
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`implied covenant of good faith and fair dealing.
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`42.
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`Cigna breached its duty of good faith and fair dealing by engaging in, without
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`limitation, the following unreasonable acts:
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`
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`a.
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`b.
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`c.
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`d.
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`failing to recognize the Surgery as a “medically necessary” procedure;
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`failing to authorize the Surgery as a “medically necessary” procedure;
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`failing to cover the Surgery as a “medically necessary” procedure;
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`ignoring the opinions of Kaminsky regarding the urgency and medical
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`necessity of the Surgery;
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`7
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`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 8 of 10
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`
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`e.
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`ignoring the medical literature reasonably available and/or provided by
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`Kaminsky regarding the medical necessity of the Surgery;
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`f.
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`failing to reasonably explain its rationale for denying pre-authorization for
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`the Surgery;
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`g.
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`h.
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`failing to expedite the appeal process;
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`refusing to authorize the Surgery or cover the cost of the Surgery without
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`conducting a reasonable investigation based on all available information;
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`
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`i.
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`not attempting in good faith to effectuate a prompt, fair, and equitable
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`settlement of Roucis’ claim for health insurance benefits;
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`h.
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`forcing Roucis to institute litigation to recover benefits owed under the
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`Policy;
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`f.
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`failing to follow Cigna’s own internal policies on determining medical
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`necessity; and
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`g.
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` engaging in other conduct prohibited by C.R.S. § 10-3-1104(1)(h).
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`43.
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`Cigna knew or recklessly disregarded the fact that its above-described conduct was
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`unreasonable.
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`44.
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`Cigna recklessly disregarded the validity of Roucis’ request for pre-authorization
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`and claim for benefits.
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`45.
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`As a direct and proximate result of Cigna’s bad faith conduct, Roucis has suffered
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`injuries, damages, and losses in an amount to be proven at trial.
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`THIRD CLAIM FOR RELIEF
` (Violation of C.R.S. §§ 10-3-1115 and -1116)
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`8
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`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 9 of 10
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`46.
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`Roucis incorporates by reference the allegations set forth with specificity in ¶¶ 1-
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`45 of this Complaint as if fully set forth.
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`47.
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`C.R.S. §§ 10-3-1115 and -1116 forbid a person engaged in the business of
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`insurance from unreasonably denying payment of a claim for benefits owed to or on behalf of
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`any first-party claimant.
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`48.
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`49.
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`50.
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`Roucis is a first-party claimant under Section 10-3-1115(1)(b)(I) and the Policy.
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`The Surgery was a covered procedure under the Policy.
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`Cigna unreasonably denied the payment of insurance benefits owed under the
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`Policy relating to the Surgery.
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`51.
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`52.
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`53.
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`There is no reasonable justification for Cigna’s denial of benefits owed.
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`Cigna’s unreasonable denial violated C.R.S. §§ 10-3-1115 and -1116.
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`As a direct and proximate result of Cigna’s statutory violation, Roucis has
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`suffered injuries, damages, and losses in an amount to be proven at trial.
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`54.
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`Pursuant to C.R.S. § 10-3-1116, Roucis is entitled to recover reasonable
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`attorneys’ fees, costs, and two times the covered benefit unreasonably denied by Cigna.
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`PRAYER FOR RELIEF
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`WHEREFORE, Roucis prays for a judgment in her favor and against Cigna for:
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`(A)
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`(B)
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`economic damages equal to the amount of benefits owed under the Policy;
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`non-economic damages to compensate her for the physical pain and suffering,
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`financial stress, worry, and inconvenience caused by Cigna’s bad faith conduct;
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`(C)
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`(D)
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`twice the covered benefit pursuant to C.R.S. § 10-3-1116;
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`attorneys’ fees and costs pursuant to C.R.S. § 10-3-1116;
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`9
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`Case 1:21-cv-02003-MEH Document 1-2 Filed 07/23/21 USDC Colorado Page 10 of 10
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`(E)
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`(F)
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`pre- and post-judgment interest as allowed by law; and
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`for such other and further relief as this Court deems just and proper.
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`PLAINTIFF DEMANDS A TRIAL BY JURY ON ALL ISSUES SO TRIABLE.
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`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
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`Respectfully submitted this 18th day of June, 2021.
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`
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`By:
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`
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`Plaintiff’s Address:
`1122 S. Flower Circle
`Lakewood, CO 80232
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`10
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