Case 3:22-cv-00280 Document 1 Filed 01/21/22 Page 1 of 6 PageID: 1
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`MANDELBAUM BARRETT, P.C.
`Steven I Adler, Esq.
`A Professional Corporation
`3 Becker Farm Road, Suite 105
`Roseland, NJ 07068
`Ph.: 973-736-4600; Fax: 973-736-4670
`Counsel for Plaintiff Christopher Ward
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`CHRISTOPHER WARD,
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`UNITED STATES DISTRICT COURT
`DISTRICT OF NEW JERSEY
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`Plaintiff,
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`NEWARK VICINAGE
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`
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`Civil Action No.:
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`COMPLAINT
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`Defendants.
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`v.
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`
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`AETNA INC. and AETNA LIFE INSURANCE
`COMPANY,
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`
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`Plaintiff Christopher Ward, residing at 536 Cokesbury Road, Annandale, New Jersey, by
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`way of Complaint against Defendants Aetna Inc., and Aetna Life Insurance Company, alleges
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`and says:
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`JURISDICTION AND VENUE
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`1. This action arises under the Employee Retirement Income Security Act of 1974
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`(“ERISA”), 29 U.S.C. Sections 1132(1), (e), (f), and (g) as well as 28 U.S.C. Section 1331, as this
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`action involves a federal question and a claim by Plaintiff for employee benefits under an employee
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`benefit plan regulated and governed under ERISA.
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`2. Venue is proper pursuant to the provisions of 29 U.S.C. Section §1132(e)(2) as a substantial
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`part of the events that give rise to Plaintiff's claims arose in the District of New Jersey and because
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`4862-3899-7514, v. 2
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`
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`MANDELBAUM BARRETT, P.C.
`Steven I Adler, Esq.
`A Professional Corporation
`3 Becker Farm Road, Suite 105
`Roseland, NJ 07068
`Ph.: 973-736-4600; Fax: 973-736-4670
`Counsel for Plaintiff Christopher Ward
`
`
`
`
`
`CHRISTOPHER WARD,
`
`UNITED STATES DISTRICT COURT
`DISTRICT OF NEW JERSEY
`
`
`Plaintiff,
`
`
`NEWARK VICINAGE
`
`
`
`
`Civil Action No.:
`
`COMPLAINT
`
`Defendants.
`
`
`v.
`
`
`
`AETNA INC. and AETNA LIFE INSURANCE
`COMPANY,
`
`
`
`
`
`
`
`
`Plaintiff Christopher Ward, residing at 536 Cokesbury Road, Annandale, New Jersey, by
`
`way of Complaint against Defendants Aetna Inc., and Aetna Life Insurance Company, alleges
`
`and says:
`
`JURISDICTION AND VENUE
`
`1. This action arises under the Employee Retirement Income Security Act of 1974
`
`(“ERISA”), 29 U.S.C. Sections 1132(1), (e), (f), and (g) as well as 28 U.S.C. Section 1331, as this
`
`action involves a federal question and a claim by Plaintiff for employee benefits under an employee
`
`benefit plan regulated and governed under ERISA.
`
`2. Venue is proper pursuant to the provisions of 29 U.S.C. Section §1132(e)(2) as a substantial
`
`part of the events that give rise to Plaintiff's claims arose in the District of New Jersey and because
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`4862-3899-7514, v. 2
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`
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`Case 3:22-cv-00280 Document 1 Filed 01/21/22 Page 2 of 6 PageID: 2
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`one or more of the breaches complained of in this complaint occurred in said District. Plaintiff
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`resides, and was denied coverage of his medical benefits, in this district.
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`PARTIES
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`3. Plaintiff Christopher Ward (“Plaintiff” or “Ward”) is a resident of New Jersey and this
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`judicial district, residing at 536 Cokesbury Road, Annandale, New Jersey 08801.
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`4. Defendant Aetna, Inc. (“Aetna, Inc.”) is, upon information and belief, a Pennsylvania
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`corporation with its’ principal place of business in Pennsylvania.
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`5. Defendant Aetna Life Insurance Company(“ALIC”) (Aetna, Inc. and ALIC, together
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`“Aetna”) is, upon information and belief, a Connecticut Company, with its’ principal place of
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`business in Connecticut.
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`6. Plaintiff is a 62-year-old male, who sought medical attention for a full body rash, presumed
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`FACTS
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`to be eczema.
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`7. After two biopsies were taken on or about October 27, 2021, Plaintiff was diagnosed with
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`stage III CTCL-MF (Mycosis Fungoides) (“MF”), a rare form of blood cancer also called
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`cutaneous T-cell lymphoma.
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`8. Symptoms of MF include weight loss, redness, itching, and an overall burning sensation
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`of one’s skin.
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`9. According to Plaintiff’s doctor at Columbia University, New York-Presbyterian Hospital,
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`Ward has a “severely atypical epidermotropic and dermal based lymphocytic infiltrate including a
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`lymphomatoid vascular reaction consistent with early plaque stage mycosis fungoides with
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`interstitial granulomatous features.” See diagnosis attached hereto as Exhibit “A”.
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`10. This diagnosis was based upon two biopsies, one taken from the left posterior neck and the
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`other from the left upper arm. The biopsies show a significantly atypical lymphocytic infiltrate.
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`4862-3899-7514, v. 2
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`Case 3:22-cv-00280 Document 1 Filed 01/21/22 Page 3 of 6 PageID: 3
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`11. Based upon reported studies for stage III MF, the median survival rate is only four to six
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`years. According to an article entitled Review of the treatment of mycosis fungoides and Sezary
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`syndrome, a copy of which is annexed hereto as Exhibit “B”, the five-year survival rate for
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`someone diagnosed with cutaneous peripheral T-cell lymphoma is only sixteen percent (16%).
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`12. To treat MF, Plaintiff was put on a chemotherapy regimen, which he is still undergoing.
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`13. Plaintiff has an insurance policy with Aetna (the “Policy”) entitled Critical Illness Plus
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`with Cancer with Recurrence, group policy number 802252, for which he, and/or his employer,
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`has paid all of the premiums. A copy of Plaintiff’s Benefit Summary is attached hereto as Exhibit
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`“C.”
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`14. The Policy, underwritten by ALIC, provides a fixed dollar benefit for covered claims of up
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`to $40,000.
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`15. The Policy makes clear that an insured, such as Ward, with this type of invasive cancer has
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`coverage under the Plan.
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`16. The Policy indicates that Aetna “will pay the applicable Cancer Benefit when an insured
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`person is diagnosed as having cancer (invasive) …” See Ex. C, p. 4.
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`17. The Policy defines “cancer (invasive)” as “the presence of malignant cells or a tumor
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`characterized by the uncontrolled and abnormal growth and spread of the invasive cells.”
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`18. Here, the blood cancer diagnosis clearly meets this definition. Photographs enclosed
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`herewith also demonstrate that this form of blood cancer has spread. See Exhibit “D” annexed
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`hereto.
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`19. Cancers that begin anywhere in the body’s lymphatic system are called lymphomas. If such
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`lymphomas have the ability to spread, they are called malignant and are, therefore, covered under
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`the Policy.
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`4862-3899-7514, v. 2
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`Case 3:22-cv-00280 Document 1 Filed 01/21/22 Page 4 of 6 PageID: 4
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`20. Despite the lymphoma being covered under the Policy, Plaintiff received a notice from
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`Aetna, dated November 9, 2021, informing him that his claim under the Policy was denied because
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`it erroneously concluded he has skin cancer.
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`21. The EOB, annexed hereto as Exhibit “E”, confirms Aetna’s error with regard to Plaintiff’s
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`medical condition. It indicates “The skin cancer benefit is not payable based on our review of the
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`information provided. Your diagnosis did not meet the criteria and/or definition stated in the Plan
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`certification.” See Ex. E, p. 1.
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`22. As stated above, Plaintiff does not have skin cancer; he has MF. In fact, Plaintiff’s
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`diagnosis confirms that problems with his skin are a reaction to his MF. See Exhibit “A”.
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`23. Plaintiff appealed from the denial of his claim because Plaintiff did not, and does not, have
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`skin cancer but suffers from a rare form of deadly lymphoma.
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`24. By letter, dated December 6, 2021, Plaintiff’s counsel submitted the appeal, explaining that
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`Defendants erroneously concluded that Plaintiff has skin cancer, as opposed to MF. A copy of this
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`submission is attached hereto as Exhibit “F”.
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`25. On December 21, 2021, Defendants’ Complaint and Appeal Analyst, Deborah H, notified
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`Plaintiff that Aetna denied his appeal, reiterating that Aetna (erroneously) continued to assert that
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`Plaintiff has skin cancer. A copy of this letter is attached as Exhibit “G”.
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`26. In Aetna’s denial letter, it wrote that “the skin cancer benefit is not payable. Based on our
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`review of the information provided, your diagnosis did not meet the criteria and/or definition stated
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`in the Critical Illness Plus with Cancer Certificate.” See Ex. G, p. 5.
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`27. Aetna also confirmed in writing that Plaintiff exhausted his internal appeals and that his
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`claim could be pursued in court.
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`Case 3:22-cv-00280 Document 1 Filed 01/21/22 Page 5 of 6 PageID: 5
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`28. Aetna’s denial of Plaintiff’s claim, in breach of the Policy, was in bad faith as it knows, or
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`clearly should know, that Plaintiff does not have skin cancer, but a covered claim of MF. This
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`diagnosis was confirmed by Ward’s main doctor at Columbia Presbyterian Hospital and his
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`diagnosis was supplied to Aetna on at least two occasions.
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`29. Aetna’s intentional and willful denial of Ward’s covered claim has cause Ward significant
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`emotional distress and mental anguish as he continues to undergo chemotherapy to deal with his
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`MF.
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`FIRST COUNT
`(ERISA)
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`30. The allegations in the foregoing paragraphs of this Verified Complaint are incorporated
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`herein by reference as if restated herein at length.
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`31. Plaintiff’s Policy with Aetna is a Plan governed by ERISA.
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`32. Plaintiff has a medical condition covered by the Policy and Aetna breached its obligations
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`under the Policy by refusing to pay Plaintiff benefits.
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`33. Under 29 U.S.C. § 1132(a)(1)(B), Plaintiff is authorized to enforce his rights under the
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`Policy and to obtain other appropriate equitable relief with respect to ERISA benefits to which he
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`is entitled.
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`34. Pursuant to ERISA, Plaintiff is entitled to benefits under the Policy and equitable relief
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`declaring and adjudging him entitled to said benefits.
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`35. Plaintiff also is entitled to, inter alia, reasonable attorneys’ fees and costs under ERISA.
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`36. Aetna’s denial of Ward’s claim was in bad faith, willful, wanton, malicious and/or in
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`reckless disregard of Ward’s rights.
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`4862-3899-7514, v. 2
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`Case 3:22-cv-00280 Document 1 Filed 01/21/22 Page 6 of 6 PageID: 6
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`WHEREFORE, Plaintiff Christopher Ward demands judgment against Defendants Aetna,
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`Inc., and Aetna Life Insurance Company, jointly, severally and/or in the alternative, as follows:
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`A. Damages;
`B. Punitive damages;
`C.
`Interest;
`D. Costs of suit;
`E. Reasonable Attorney’s fees;
`F. Equitable and/or declaratory relief requiring Defendants to provide all
`coverage under the referenced ERISA plan; and
`G. Such further relief as this Court deems just and equitable under the
`circumstances.
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`DATED: January 21, 2022
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`Mandelbaum Barrett P.C.
`Attorneys for Plaintiff, Christopher Ward
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`By:
`/s/ Steven Adler, Esq.
` Steven Adler, Esq.
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`4862-3899-7514, v. 2
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