Case: 1:22-cv-02982 Document #: 1 Filed: 06/07/22 Page 1 of 7 PageID #:1
`
`IN THE UNITED STATES DISTRICT COURT
`FOR THE NORTHERN DISTRICT OF ILLINOIS
`EASTERN DIVISION
`
`Case No.: l:22-CY -02982
`
`) ) ) ) ) ) ) ) ) ) ) )
`
`ADVANCED PHYSICAL MEDICINE
`OF YORKVILLE, LTD., an Illinois medical
`corporation,
`
`Plaintiff,
`
`VS
`
`CIGNA HEALTH AND LIFE INSURANCE
`COMPANY, a Pennsylvania Corporation, and
`zuTCHIE BROS. AUCTIONEERS (AMERICA),
`INC., a Nebraska 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 HEALTH AND LIFE INSURANCE COMPANY, INC., a
`
`Connecticut Corporation, and RITCIE BROS. AUCTIONEERS (AMERICA), INC., a Nebraska
`
`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(a)(1)(B) and for statutory penalties pursuant to29 U.S.C. $ 1132(aXl)(A), as
`
`defined in 29 U.S.C. $ I 132(c)(1), modified by 29 C.F.R. $ 2575.502c-1.
`2.
`treatments and therapeutic exercises, defined further below ("the Services") between the dates of
`
`Plaintiff treated patient Robert Slavin ("Patient") with chiropractic manipulative
`
`January 22,2021and March l,202L The Services are covered under Patient's health benefits
`
`
`
`IN THE UNITED STATES DISTRICT COURT
`FOR THE NORTHERN DISTRICT OF ILLINOIS
`EASTERN DIVISION
`
`Case No.: l:22-CY -02982
`
`) ) ) ) ) ) ) ) ) ) ) )
`
`ADVANCED PHYSICAL MEDICINE
`OF YORKVILLE, LTD., an Illinois medical
`corporation,
`
`Plaintiff,
`
`VS
`
`CIGNA HEALTH AND LIFE INSURANCE
`COMPANY, a Pennsylvania Corporation, and
`zuTCHIE BROS. AUCTIONEERS (AMERICA),
`INC., a Nebraska 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 HEALTH AND LIFE INSURANCE COMPANY, INC., a
`
`Connecticut Corporation, and RITCIE BROS. AUCTIONEERS (AMERICA), INC., a Nebraska
`
`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(a)(1)(B) and for statutory penalties pursuant to29 U.S.C. $ 1132(aXl)(A), as
`
`defined in 29 U.S.C. $ I 132(c)(1), modified by 29 C.F.R. $ 2575.502c-1.
`2.
`treatments and therapeutic exercises, defined further below ("the Services") between the dates of
`
`Plaintiff treated patient Robert Slavin ("Patient") with chiropractic manipulative
`
`January 22,2021and March l,202L The Services are covered under Patient's health benefits
`
`
`
`Case: 1:22-cv-02982 Document #: 1 Filed: 06/07/22 Page 2 of 7 PageID #:2
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`plan, Cigna Plan No. xxxx2807 ("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
`
`of the Patient Consent and Legal Assignment of Benefits dated January 22,2021 is attached as
`
`Exhibit "A."
`4.
`
`Count I of this action is brought to recover health benefits due to Plaintiff under the
`
`Plan for claims that Defendant arbitrarily and capriciously denied. Count II of this action is brought
`
`to collect statutory penalties against Defendant for Defendant's failure to provide Plaintiff with
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`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.
`DEfCNdANt, CIGNA HEALTH AND LIFE INSURANCE COMPANY
`6,
`("CIILIC"), the Plan Provider for the Plan, is a Connecticut corporation with its principal
`place of business located at 900 Cottage Grove Road, Bloomfield, CT 06002. Upon
`
`information and belief, CHLIC 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-02982 Document #: 1 Filed: 06/07/22 Page 3 of 7 PageID #:3
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`7.
`
`Defendant RITCHIE BROS. AUCTIONEERS (AMERICA), INC. ("Ritchie
`
`Bros."), the Plan Administrator for the Plan, is a Nebraska corporation, licensed to transact
`
`business in the State of Illinois, with its principal place of business located at 4000 Pine Lake
`
`Road, Lincoln, NE 68516, and its and its Illinois registered agent located at 801 Adlai
`
`Stevenson Drive, Springfield, IL 62703. Upon information and belief, Ritchie Bros. 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.
`
`9.
`
`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. All claims in this complaint pose questions of federal law arising under
`
`provisions of ERISA. Additionally,2g U.S.C. $ 1132(e)(1) grants the U.S. district courts exclusive
`jurisdiction of claims brought under 29 U.S.C. $ 1132(aX1)(A) and concurrent jurisdiction for
`
`claims brought under 29 U.S.C. $ 1132(aX1XB).
`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.
`
`1 I . Venue is proper in the Northern District of Illinois under 28 U.S.C. $ 1391(b)(2) as
`
`a substantial part of the events giving rise to these claims occurred in this district and under 29
`
`U.S.C. g 1132(eX2) as the district in which the health benefits plan was administered.
`
`3
`
`
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`Case: 1:22-cv-02982 Document #: 1 Filed: 06/07/22 Page 4 of 7 PageID #:4
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`Common Facts
`
`12. Plaintiff submitted approval to CHLIC for the Services for Patient, which included
`
`17 office visits/chiropractic manipulative adjustments and therapeutic exercise services, between
`
`January 22,202I and March I,2021. The Services were covered under the Plan. As Patient's
`
`authorized representative, Plaintiff submitted claims to CHLIC on Patient's behalf for the Services.
`
`13. CHLIC agreed to pay for the Services, but at an incoruect and discounted amount.
`A true and correct copy of the denial is summarized on Exhibit o'B." Ritchie Bros. did not pay the
`
`denied Services following CHLIC's denial of Services.
`
`14. On July 26,202|,as Patient's authorized representative, Plaintiff submitted its first
`appeal of the denied Services for service dates January 22, 202I through March I, 2021, on the
`
`grounds that "we called and verified the insurance benefits for this member in January, we were
`
`told by 3 different representatives that the OON allowables are set at200% Medicare. All of these
`
`claims had allowable amounts below thatrate." 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 July 26,2021 appeal is attached as Exhibit'0C."
`15. No response was received from CHLIC in regards to Plaintiff s first appeal.
`16. On September 16, 2021, as Patient's authorized representative, Plaintiff submitted
`
`a second appeal of the claim denials for the Services to CHLIC. A true and correct copy of the
`
`September 16,2021appeal is attached as Exhibit "D."
`17. On October 18,2021, CHLIC responded to the second appeal, including a copy of
`
`Patient's SPD but nothing else. A true and correct copy of said denial is attached as Exhibit "E."
`
`Ritchie Bros. did not pay the denied Services following CHLIC's denial of Services.
`
`4
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`Case: 1:22-cv-02982 Document #: 1 Filed: 06/07/22 Page 5 of 7 PageID #:5
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`18. On November 4,2021, as Patient's authorized representative, Plaintiff submitted a
`
`third appeal of the claim denials for the Services to CHLIC, with an outstanding balance for
`
`Services provided under the Plan of $8,147.92. 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 November 4,2021appeal is attached as Exhibit "F."
`lg. To date, CHLIC has not responded to the third appeal. Ritchie Bros. has continued
`
`to fail to pay the denied Services.
`20. To date, Plaintiff s the claims for Services of $8,147 .92 remain unpaid.
`
`Count I:
`
`of Renefits Due Under Plan Pursuant to 29 U.S.C. S 11 32(a)(1)(R)
`
`I-20. Plaintiff realleges paragraphs 1-20 as though fully set forth herein.
`21. Plaintiff brings Count I under 29 U.S.C. $ 1132(a)(1)(B) to recover benefits due
`
`Plaintiff under Patient's Plan that CHLIC arbitrarily and capriciously denied.
`22. Plaintiff has exhausted its administrative remedies regarding the disputed denials
`
`of benefits for the Services under 29 C.F.R. $ 2560.503-10)(1). CHLIC failed to follow procedures
`
`consistent with a full and fair review of Plaintifls appeal as required by 29 U.S.C. $ 1133(2) and
`
`defined under 29 C.F.R. $ 2560.503-1.
`23. CHLIC 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 CHLIC
`
`provided a reason, it was not rationally based on a review of the medical records provided to it.
`
`24. CHLIC 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 2s60.s03-1(iX5).
`
`5
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`Case: 1:22-cv-02982 Document #: 1 Filed: 06/07/22 Page 6 of 7 PageID #:6
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`25. Ritchie Bros. is liable as a fiduciary under the Plan for CHLIC's denials and for
`
`failure to pay the claims for the denied Services.
`26. Therefore, Plaintiff is entitled to recover the full amount of its claim for $8,T47.92
`
`from Defendants.
`27. Plaintiff is entitled to recover its reasonable attorney's fees under 29 U.S.C. $
`
`1 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
`
`favor and against Defendants, CIGNA HEALTH AND LIFE INSURANCE COMPANY, INC.
`
`and RITCIE BROS. AUCTIONEERS (AMERICA), [NC., in the amount of $8,147.92 plus
`
`attorney's fees and costs and such other relief as this Court deems just.
`
`Count II:
`
`of Statutorv
`
`Pursuant to 29 U.S.C. S I132(a)(1)(A)
`
`l-21. Plaintiff realleges paragraphs l-27 as though fully set forth herein.
`28. 29CFR 52520.104b-1(a) and29U.S.C. 1024(bX1)requireaplanadministratorto
`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.
`
`29. 29 U.S.C. g 1132(c)(1)(A), as modified by 29 C.F.R. 52575.502c-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."
`30. Plaintiff is a participant or beneficiary under the Plan administered by Defendants
`
`under the assignment of benefits attached as Exhibit" A." Plaintiff may therefore bring suit against
`
`Defendant under 29 U.S.C. $ 1132(a)(1)(A) to recover the above referenced statutory penalties'
`
`6
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`Case: 1:22-cv-02982 Document #: 1 Filed: 06/07/22 Page 7 of 7 PageID #:7
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`31. CHLIC is responsible for administering the Plan in compliance with the
`
`requirements of 29 U.S.C. $ 1024(bX2) under the Plan.
`32. Plaintiff requested the documentation on which CHLIC based its denial. CHLIC
`
`delayed providing the SPD by more than four months. Apart from the SPD, CHLIC has yet to
`
`provide the requested documents.
`
`33. Therefore, Plaintiff is entitled to recover a statutory penalty against CHLIC of $110
`
`per day for its delay in providing requested Plan documents.
`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:
`
`Award Plaintiff recovery of statutory penalties of $110 per day pursuant to 29
`
`A.
`U.S.C. g 1132(cX1)(A), as modified by 29 C.F.R. 52575.502c-1, from July 26,2021to date for
`
`CHLIC's failure to provide requested Plan documents, which continue to accrue daily; and
`B.
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`Award Plaintiff the cost of reasonable attorney's fees as allowed under 29 U.S.C.
`
`$ 1132(eXl).
`
`Respectfully submitted,
`
`Lnw OnntcES oF McLAUGHLIN & AssoclarEs, P.C.
`
`By
`
`One of the Plaintifls Attorneys
`
`Kenneth S. Mclaughlin, Jr.
`ARDC No. 6229828
`Lew Onnrcps on McLAUcHLIN & AssocterEs, P.C.
`1 E. Benton Street, Suite 301
`Aurora, IL 60505
`630-230-8434
`630-230-8435 fax
`kmclaughlin@ma-lawpc. com
`
`7
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