Case: 1:22-cv-01575 Document #: 1 Filed: 03/25/22 Page 1 of 8 PageID #:1
`
`IN THE UNITED STATES DISTRICT COURT
`FOR THE NORTHERN DISTRICT OF ILLINOIS
`EASTERN DIVISION
`
`Case No.:
`
`) ) ) ) ) ) ) ) ) ) ) )
`
`ADVANCED PHYSICAL MEDICINE
`OF YORKVILLE, LTD., an Illinois medical
`corporation,
`
`Plaintiff,
`
`vs.
`
`CIGNA HEALTHCARE OF ILLINOIS, INC., AN
`Illinois corporation, and CIGNA HEALTH
`MANAGEMENT, INC., a Delaware
`Corporation,
`
`Defendant.
`
`COMPLAINT
`
`NOW COMES the Plaintiff, ADVANCED PHYSICAL MEDICINE OF YORKVILLE,
`
`LTD., by and through its attorneys, LAW OFFICES OF MCLAUGHLIN & ASSOCIATES, P.C.,
`
`and for its Complaint against CIGNA HEALTHCARE OF ILLINOIS, INC., an Illinois
`
`corporation, and CIGNA HEALTH MANAGEMENT,INC., a Connecticut Corporation, states as
`
`follows:
`
`Nature of the Action
`
`1.
`
`This action is brought under provisions of the Employee Retirement Income
`
`Security Act (ERISA) to recover benefits due under the terms of a health benefits plan under 29
`
`U.S.C. g 1132(aX1)(B) and for statutory penalties pursuant to 29 U.S.C. $ 1132(a)(l)(A), as
`
`defined in 29 U.S.C. $ 1132(cX1), modifiedby 29 C.F.R. $ 2575.502c-1.
`2.
`
`Plaintiff treated patient Deborah Priebe ("Patient") with chiropractic manipulative
`
`treatments and therapeutic exercises, defined fuither below ("the Services") between the dates of
`
`June25,2020,and March 27,202L The Services are covered under Patient's health benefits plan,
`
`
`
`IN THE UNITED STATES DISTRICT COURT
`FOR THE NORTHERN DISTRICT OF ILLINOIS
`EASTERN DIVISION
`
`Case No.:
`
`) ) ) ) ) ) ) ) ) ) ) )
`
`ADVANCED PHYSICAL MEDICINE
`OF YORKVILLE, LTD., an Illinois medical
`corporation,
`
`Plaintiff,
`
`vs.
`
`CIGNA HEALTHCARE OF ILLINOIS, INC., AN
`Illinois corporation, and CIGNA HEALTH
`MANAGEMENT, INC., a Delaware
`Corporation,
`
`Defendant.
`
`COMPLAINT
`
`NOW COMES the Plaintiff, ADVANCED PHYSICAL MEDICINE OF YORKVILLE,
`
`LTD., by and through its attorneys, LAW OFFICES OF MCLAUGHLIN & ASSOCIATES, P.C.,
`
`and for its Complaint against CIGNA HEALTHCARE OF ILLINOIS, INC., an Illinois
`
`corporation, and CIGNA HEALTH MANAGEMENT,INC., a Connecticut Corporation, states as
`
`follows:
`
`Nature of the Action
`
`1.
`
`This action is brought under provisions of the Employee Retirement Income
`
`Security Act (ERISA) to recover benefits due under the terms of a health benefits plan under 29
`
`U.S.C. g 1132(aX1)(B) and for statutory penalties pursuant to 29 U.S.C. $ 1132(a)(l)(A), as
`
`defined in 29 U.S.C. $ 1132(cX1), modifiedby 29 C.F.R. $ 2575.502c-1.
`2.
`
`Plaintiff treated patient Deborah Priebe ("Patient") with chiropractic manipulative
`
`treatments and therapeutic exercises, defined fuither below ("the Services") between the dates of
`
`June25,2020,and March 27,202L The Services are covered under Patient's health benefits plan,
`
`
`
`Case: 1:22-cv-01575 Document #: 1 Filed: 03/25/22 Page 2 of 8 PageID #:2
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`CIGNA East, Plan No. xxxx224 ("the Plan"). The Plan is a group health benefits plan subject to
`
`ERISA.
`3.
`
`Plaintiff is the assignee of benefits for health care services Plaintiff provided to
`
`Patient and Patient's designated authorized representative. Patient has conveyed to Plaintiff all
`
`rights to pursue recovery of benefits due under the Plan for the Services and to bring derivative
`
`actions on his behalf to recover such benefits and to pursue any other available remedies under the
`
`law. This assignment was in effect during all times relevant to this Complaint. A true and correct
`
`ofthe Patient Consent and Legal Assignment of Benefits dated June25,2020 is attached as Exhibit
`
`" A.t'
`
`4.
`
`Count I of this action is brought to recover health benefits due to Plaintiff under the
`
`Plan for claims that Defendarrtarbrtrarily and capriciously denied. Count II of this action is brought
`
`to collect statutory penalties against Defendant for Defendant's failure to provide Plaintiff with
`
`certain Plan documents requested by Plaintiff.
`
`Parties
`
`5.
`
`Plaintiff, Advanced Physical Medicine of Yorkville, Ltd. is an Illinois medical
`
`corporation with its principal place of business located at207 Hillcrest Avenue, Suite A, Yorkville,
`
`Kendall County, Illinois 60560. Plaintiff provided chiropractic and other medical treatment to
`
`Patient under the Plan as set forth herein.
`6.
`
`Defendant, CIGNA HealthCare of Illinois, Inc., ("CHC"), the Plan Provider for
`
`the Plan, is an Illinois corporation with its principal place of business located at 525 W.
`
`Monroe St., Chicago, IL 60661, and its registered agent located at208 S. LaSalle St., Suite
`
`814, Chicago,IL 60604. Upon information and belief, CHC retained fiduciary responsibilities
`
`under the Plan to pay claims under the Plan, including those of Patient's.
`
`2
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`Case: 1:22-cv-01575 Document #: 1 Filed: 03/25/22 Page 3 of 8 PageID #:3
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`7. Defendant CIGNA Health Management, Inc', ("CHM"), the Plan
`
`Administrator for the Plan, is a Delaware corporation, licensed to transact business in the State
`
`of Illinois, with its principal place of business located at 1601 Chestnut St., Philadelphia, PA
`lglg2, and its Illinois registered agent located at208 S. LaSalle St., Suite 814, Chicago, IL
`
`60604. Upon information and belief, CHM had fiduciary responsibilities under the Plan to
`
`administrator and make proper determinations under the Plan for payment of claims, including
`
`those of Patient's.
`
`8.
`
`g.
`
`Patient resides in Yorkville, Kendall County, Illinois.
`
`Jurisdiction and Venue
`
`This Court has subject matter jurisdiction under 28 U.S.C. $ 1331 for all claims
`
`asserted in this Complaint. A11 claims in this complaint pose questions of federal law arising under
`
`provisions of ERISA. Additionally,2g U.S.C. $ 1 132(e)(1) grants the U.S. district courts exclusive
`
`jurisdiction of claims brought under 29 U.S.C. $ 1132(aX1)(A) and concunent jurisdiction for
`
`claims brought under 29 U.S.C. $ 1132(a)(1)(B).
`10. This Court has personal jurisdiction over Defendants because as Plan Administrator
`
`and Plan Provider, Defendants administered and were responsible for providing benefits under
`
`Patient's Plan in the Northern District of Illinois and denied claims under the Plan's coverage for
`
`services rendered in the Northern District of Illinois.
`
`I 1. Venue is proper in the Northern District of Illinois under 28 U.S.C. $ 1391(b)(2) as
`
`a substantialpart of the events giving rise to these claims occurred in this district and under 29
`
`U.S.C. g 1132(e)(2) as the district in which the health benefits plan was administered.
`
`3
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`Case: 1:22-cv-01575 Document #: 1 Filed: 03/25/22 Page 4 of 8 PageID #:4
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`Common Facts
`
`12. Plaintiff submitted approval to CHM for the Services for Patient, which included
`27 office visits/chiropractic manipulative adjustments and 27 therapeutic exercise services,
`
`between |une25,2020, and March 27,202L The Services were covered under the Plan. As
`
`Patient's authorized representative, Plaintiff submitted claims to CHM on Patient's behalf for the
`
`Services.
`
`13. On or about October 6,2020, CHM agreed to pay for 18 office visits/chiropractic
`
`manipulative adjustments and 18 therapeutic exercise services but denied the remaining 9 office
`
`visits/chiropractic manipulative adjustments and 9 therapeutic exercise services on two (2)
`
`grounds: (a) "Your [the Patient's] condition is chronic....We need to know your response to care
`
`before more treatment can be considered." (b) Your [the Patient's] condition was not caused by
`
`trauma. . ..This type of condition should respond well and need less care." A true and correct copy
`of the denial is summarized on Exhibit "B." CHC did not pay the denied Services following
`
`CHM's denial of Services.
`14. On October 8,2020, as Patient's authorized representative, Plaintiff submitted its
`
`first appeal of the denied Services for service dates June 29 , 2020 through October 8, 2020 on the
`
`grounds that "it fthe denial] fails to provide the specific reason or reasons for denial and the specific
`
`reference to pertinent plan provisions on which the denial is based." Plaintiff s appeal included a
`
`request for Patient's SPD, a reviewing physician's report, and all pertinent information related to
`
`the denial of Services. A true and correct copy of the October 8,2020 appeal is attached as Exhibit
`
`"c."
`
`15. On November 18, 2020, CHM responded to Plaintiffs first appeal and denied
`
`coverage for the Services under CPT codes 99214 and 98940 on the grounds that the Services were
`
`4
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`Case: 1:22-cv-01575 Document #: 1 Filed: 03/25/22 Page 5 of 8 PageID #:5
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`not medically necessary because "the fPatient's medical] records do not include objective
`measurements of improvement." A true and correct copy of said denial is attached as Exhibit "D."
`
`CHC did not pay the denied Services following CHM's denial of Services.
`16. Plaintiff provided CHM with Patient's medical records that showed objective
`
`measurements of 22.5-26.7% improvement, which CHM had for review prior to its November 18,
`
`2020 denial.
`
`17 . On December 1, 2020, as Patient's authorized representative, Plaintiff submitted a
`
`second appeal of the claim denials for the Services to CHM, updated to include service dates
`
`through November 12,2020. This appeal directed CHM's attention to medical records from
`
`August 3,2020-August 3I,2020 of 22.5% improvement and from August3l,2}2}-November 3,
`
`2020 of 26.7% improvement. A true and correct copy of the December l't appeal is attached as
`
`Exhibit "E."
`18. On January 6, 202I, CHM denied the second appea| again claiming that the
`
`treatment was not medically necessary because "the records do not include successive objective
`
`measurements for improvement." A true and correct copy of said denial is attached as Exhibit
`
`"F." CHC did not pay the denied Services following CHM's denial of Services.
`D . On May 20, 2021 , as Patient's authorized representative, Plaintiff submitted a third
`
`appeal of the claim denials for the Seruices to CHM, with an outstanding balance for Services
`
`provided under the Plan of $18,975.77. This appeal included all previously provided medical
`
`records and appeals, as referenced in "Enclosures, 2. Previously submitted requests and appeals."
`
`A true and correct copy of the May 20th appeal is attached as Exhibit "G."
`20. To date, CHM has not responded to the third appeal. CHC has continued to fail to
`
`pay the denied Services.
`
`5
`
`
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`Case: 1:22-cv-01575 Document #: 1 Filed: 03/25/22 Page 6 of 8 PageID #:6
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`21. To date, Plaintiff s the claims for Services of $18,975.77 rcmainunpaid.
`
`Count I: Recoverv of Benefits Due Under Plan Pursuant to 29 U.S.C. Q 1132(aX1XB)
`
`l-21. Plaintiff realleges paragraphs l-21 as though fully set forth herein.
`22. Plaintiff brings Count I under 29 U.S.C. $ 1132(a)(1)(B) to recover benefits due
`
`Plaintiff under Patient's Plan that CHM arbitrarily and capriciously denied.
`
`23. Plaintiff has exhausted its administrative remedies regarding the disputed denials
`
`of benefits for the Services under 29 C.F.R. $ 2560.503-t(lx1). CHM failed to follow procedures
`
`consistent with a full and fair review of Plaintiff s appeal as required by 29 U.S.C. $ 1 133(2) and
`
`defined under 29 C.F.R. $ 2560.503-1.
`24. CHM failed to provide the specific reason or reasons for denial and the specific
`
`reference to pertinent plan provisions on which the denial was based, or to the extent CHM
`
`provided a reason, it was not rationally based on a review of the medical records provided to it.
`
`25. CHM did not provide Plaintiff with the reviewing physician's report or any
`
`communication relevant to the Patient's adverse benefit determination upon written request as
`
`required by 29 U.S.C. 1024(b)(4) and29 CFR 2560.503-1(ixs).
`
`26. CHC is liable as a fiduciary under the Plan for CHM's denials and for failure to pay
`
`the claims for the denied Services.
`27 .
`
`Therefore, Plaintiff is entitled to recover the full amount of its claim for $18,975.77
`
`from Defendants.
`
`28. Plaintiff is entitled to recover its reasonable attorney's fees under 29 U.S.C. $
`
`I 1 32(gX1 ) from Defendants.
`WHEREFORE, for the foregoing reasons, Plaintiff ADVANCED PHYSICAL
`
`MEDICINE OF YORKVILLE, LTD., respectfully requests this Court to enter judgment in its
`
`5
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`
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`Case: 1:22-cv-01575 Document #: 1 Filed: 03/25/22 Page 7 of 8 PageID #:7
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`,
`
`favor and against Defendants, CIGNA HEALTHCARE OF ILLINOIS, INC. and CIGNA
`
`HEATHCARE MANAGEMENT, INC., in the amount of $18,975.77 plus attorney's fees and
`
`costs and such other relief as this Court deems just.
`
`Count II: Recoverv of Statutorv Penalties Pursuant to 29 U
`
`E I132(a)(l)(A)
`
`l-28. Plaintiff realleges paragraphs 1-28 as though fully set forth herein.
`29. 29 CFR 52520.104b-1(a) and29 U.S.C. 1024(bX1) require aplan administratorto
`
`furnish a copy of Plan documents, including but not limited to the summary plan document
`
`("SPD"), to a participant or beneficiary within ninety (90) days of a written request.
`
`30. 29 U.S.C. g 1132(c)(1)(A), as modified by 29 C.F.R. 5 2575.502c-1, provides for
`
`a penalty of up to $110.00 per day to be applied to any plan administrator who "fails or refuses to
`
`comply with a request for any information which such administrator is required by this subchapter
`
`to furnish to a participant or beneficiary [. . .] within 30 days."
`31. Plaintiff is a participant or beneficiary under the Plan administered by Defendant
`
`under the assignment of benefits attached as Exhibit "A." Plaintiff may therefore bring suit against
`
`Defendant under 29 U.S.C. $ 1132(aX1)(A) to recover the above referenced statutory penalties.
`32. CHM is responsible for administering the Plan in compliance with the requirements
`
`of 29 U.S.C. $ 1024(b)(2) under the Plan.
`33. Plaintiff requested the documentation on which CHM based its denial. CHM
`
`delayed providing the SPD by 8 months. Apart from the SPD, CHM has yet to provide the
`
`requested documents.
`
`34. Therefore, Plaintiff is entitled to recover a statutory penalty against CHM of $1 10
`
`per day for its delay in providing requested Plan documents.
`
`7
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`Case: 1:22-cv-01575 Document #: 1 Filed: 03/25/22 Page 8 of 8 PageID #:8
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`WHEREFORE, for the foregoing reasons, Plaintiff ADVANCED PHYSICAL
`
`MEDICINE OF YORKVILLE, LTD., respectfully requests this Court to enter judgment in its
`
`favor and against Defendant, CIGNA HEALTHCARE MANAGEMENT, INC., as follows:
`A. Award Plaintiff recovery of statutory penalties of $110 per day pursuant to 29
`U.S.C. g 1132(c)(1)(A), as modified by 29 C.F.R. 52575.502c-1, from August 8,2020 to date for
`
`CHM's failure to provide requested Plan documents, which continue to accrue daily; and
`B. Award Plaintiff the cost of reasonable attorney's fees as allowed under 29 U.S.C.
`
`$ 1132(gX1).
`
`Respectfully submitted,
`
`Law OrncES oF McLAUGHLIN & AssocrerEs, P.C.
`
`By:
`
`One of the P
`
`s Attorneys
`
`Kenneth S. Mclaughlin, Jr.
`ARDC No. 6229828
`Lew Orn'rcES oF McLAUGHLIN & AssocnrEs, P.C.
`1 E. Benton Street, Suite 301
`Aurora,IL 60505
`630-230-8434
`630-230-8435 fax
`kmcl aughl in@ma-lawpc. co m
`
`8
`
`
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