throbber
Case 1:21-cv-01549 Document 1 Filed 03/24/21 Page 1 of 22 PageID #: 1
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`UNITED STATES DISTRICT COURT
`EASTERN DISTRICT OF NEW YORK
`
`x
`
`NEUROLOGICAL SURGERY PRACTICE OF
`LONG ISLAND, PLLC,
`
`: COMPLAINT
`
`Plaintiff,
`
`Docket No.
`
`-against-
`
`•
`CIGNA HEALTH AND LIFE INSURANCE
`COMPANY and CONNECTICUT GENERAL LIFE : JURY TRIAL DEMANDED
`INSURANCE COMPANY,
`
`Defendants.
`
`x
`
`Plaintiff, Neurological Surgery Practice of Long Island, PLLC ("Neurological Surgery"),
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`by its attorneys, Harris Beach, PLLC, alleges for its Complaint against Defendants, Cigna Health
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`and Life Insurance Company and Connecticut General Life Insurance Company ("Cigna"), that:
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`INTRODUCTION
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`1.
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`Plaintiff is Neurological Surgery, a Long Island-based medical practice, which
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`brings this lawsuit against Cigna because Cigna has failed to properly and timely honor its
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`obligation to pay Neurological Surgery for medically necessary services that Neurological
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`Surgery provided to the members and/or subscribers of Cigna's health plans and their
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`beneficiaries (collectively, "Cigna Members").
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`2.
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`As explained below, Neurological Surgery is the largest private neurosurgery
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`practice on Long Island and in the tristate area. Its award-winning specialists are among the best
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`neurosurgeons in New York City and on Long Island and serve as Chiefs of Neurosurgery in
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`some of the most prestigious hospitals on Long Island.
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`5909055v.1
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`3.
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`Neurological Surgery maintains offices in Great Neck, Rockville Centre, Lake
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`Success, Bethpage, Commack, West Islip, Port Jefferson Station, Patchogue, Queens, and
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`Manhattan. It has developed Centers of Excellence in a wide variety of neurosurgery and related
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`subspecialties, including a Brain Tumor Center, Spine Center, Trigeminal Neuralgia and Face
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`Pain Center, Cerebrovascular/Neuroendovascular Center, Pediatric Neurosurgery Center,
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`General Neurosurgery Center, Movement Disorder Center, Epilepsy Center, Concussion Center,
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`Stereotactic Radiosurgery Center, Chiari Malformation Center, and Pain Center.
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`4.
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`Upon information and belief, Cigna is among the largest health insurers in the
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`United States. Cigna boasts that its global network of over 1.5 million providers, clinics, and
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`facilities manages care for over 17 million subscribers in its medical plans alone. The company
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`ranks number 13 on Forbes' 2020 Fortune 500 list, and its total revenues in 2019 exceeded $153
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`billion dollars.
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`5.
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`Cigna enters into agreements with health care providers whereby the providers
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`join its "provider networks." The physicians that join the provider network agree to provide
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`health care services to members of Cigna's health plans at contractually agreed upon
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`reimbursement rates, which are typically discounted rates compared to the providers' usual and
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`customary rates. Such providers are known as "in-network" providers.
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`6.
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`Other providers, like Neurological Surgery, do not enter into contracts with
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`Cigna, and bill the usual, customary, and reasonable charges for the services rendered. Such
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`providers are known as "out-of-network" or "non-participating" providers.
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`7.
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`Upon information and belief, a substantial number of Cigna's agreements with its
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`subscribers or members and their beneficiaries give Cigna Members the right to seek medically
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`necessary treatment from health care providers who are out-of-network/non-participating
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`providers in Cigna's health care networks.
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`8.
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`Upon information and belief, under these agreements, when an out-of-network
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`provider renders medically necessary treatment to an Cigna Member, Cigna is obligated to
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`reimburse the Cigna Member or the Cigna Member's out-of-network provider at the usual,
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`customary, and reasonable charges for the services rendered, less any co-payment, co-insurance,
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`member out-of-pocket, or deductible amounts. (The usual, customary, and reasonable rate is
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`referred to herein as the "UCR Rate.")
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`9.
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`By its own choice, Neurological Surgery is not a participating provider in Cigna's
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`networks. Notwithstanding Neurological Surgery's status as a non-participating provider,
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`Neurological Surgery routinely receives authorization from Cigna to provide services to Cigna
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`Members, and receives assignments of benefits from its patients who are Cigna Members to
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`permit Neurological Surgery to bill directly to, and receive payment directly from, Cigna.
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`10.
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`This litigation arises primarily out of Cigna's wrongful failure and refusal to
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`reimburse Neurological Surgery — in many cases, at all, and in other cases, at anything more than
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`a dramatically reduced rate — for medically necessary services that its surgeons provided to
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`Cigna Members.
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`11.
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`As set forth below, by Cigna's persistent refusal to pay for Neurological
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`Surgery's services it has breached myriad legal obligations to Neurological Surgery and the
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`Cigna Members. Accordingly, Neurological Surgery is entitled to the relief demanded in this
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`Complaint.
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`PARTIES
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`12.
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`Plaintiff, Neurological Surgery Practice of Long Island, PLLC, is a New York
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`professional service limited liability corporation with its principal place of business located at
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`100 Merrick Road, Suite 128W, Rockville Centre, New York.
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`13.
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`Neurological Surgery Practice of Long Island, PLLC was formed in August 2020,
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`and, because of a merger in December 2020, is the corporate successor of Neurological Surgery,
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`P.C.
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`14.
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`Upon information and belief, Defendant Cigna is a Connecticut for-profit health
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`insurer with a principal place of business located at 900 Cottage Grove Road, Bloomfield, CT
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`06002.
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`FACTUAL ALLEGATIONS COMMON TO ALL CLAIMS
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`Cigna Has Failed to Pay Neurological Surgery's Out-of-Network
`Claims at All, or Has Failed to Pay at the Correct Rate
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`15. Many of the patients who seek out and are treated by Neurological Surgery have
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`complex, and often emergent, neurological conditions requiring neurosurgical procedures and
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`treatment.
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`16.
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`Neurological Surgery's physicians perform these procedures at hospitals and
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`other healthcare facilities located throughout the New York metropolitan area.
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`17. A significant number of Neurological Surgery's patients have health insurance
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`coverage from Cigna, or are members, subscribers, or beneficiaries of group health plans for
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`which Cigna is the plan sponsor or administrator.
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`18.
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`As set forth in detail below, in addition to offering fully-insured health plans,
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`Cigna acts as the plan sponsor or administrator of self-insured group health plans by making
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`determinations regarding plan interpretation, coverage, the awarding or denial of benefits, the
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`processing and determination of appeals, and the payment of benefits.
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`19. A substantial number of Cigna's agreements with its subscribers or members give
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`these Cigna Members the right to seek medically necessary treatment from health care providers
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`who are not participating providers in Cigna's health care networks.
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`20.
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`Additionally, upon information and belief, Cigna's agreements with its members
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`routinely assure Cigna Members that, in the event that a Cigna Member requires care and
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`treatment on an emergency basis, such services will be paid for in full by Cigna, without regard
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`for whether the provider who performed the emergency services was in-network, or out-of-
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`network.
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`21.
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`Under these agreements, when an out-of-network provider renders medically
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`necessary treatment to a Cigna Member, Cigna is obligated to reimburse the Cigna Member or
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`out-of-network provider at the provider's billed charges, or at least at the UCR Rate.
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`22.
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`Further, under Section 2719A(b) of the Public Health Service Act, 42 U.S.C. §
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`300gg-19a(b), and 29 C.F.R. § 2590.715-2719A(b), Cigna, as the sponsor or administrator of
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`any self-insured group health plan, must provide coverage for out-of-network emergency health
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`care services, and must do so at the greatest of (a) the median in-network rate that the plan pays
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`for the same services; (b) the rate that the plan pays for out-of-network services, which is
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`typically based upon the UCR Rate; and (c) the rate offered by Medicare.
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`5
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`23.
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`In addition, Cigna may not impose any greater administrative requirement or
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`limitation on coverage for out-of-network emergency services than it does for in-network
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`emergency services, nor can it impose greater co-payments, co-insurance, member out-of-pocket,
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`or deductible amounts for its members for out-of-network emergency services than it does for in-
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`network emergency services.
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`24.
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`Similarly, Sections 3216(i)(9), 3221(k)(4), and 4303(a)(2) of the New York
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`Insurance Law require Cigna to provide members of its fully-insured plans with coverage for
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`medically necessary emergency medical services. Additionally, Sections 3217-a(a)(8),
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`3221(k)(4), 4303(a)(2), and 4900(c) of the New York Insurance Law, and Section 4408(1)(h) of
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`the New York Public Health Law, require that Cigna, when offering a managed care product,
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`hold their members harmless for any non-participating provider charges for emergency services
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`that exceed the in-network copayment, coinsurance, or deductible.
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`25.
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`Neurological Surgery routinely receives authorization from Cigna to treat Cigna
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`Members, or does so on an emergency basis.
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`26.
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`Neurological Surgery routinely receives assignments of benefits from its patients
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`who are Cigna Members, assigning to Neurological Surgery all rights the Cigna Member has
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`under its agreements with Cigna to bill Cigna for the services, and to pursue and receive payment
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`directly from Cigna.
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`27. When Neurological Surgery patients elect to assign their benefits under their
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`Cigna health plans, they execute an assignment of benefits form. In the case of elective and non-
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`emergency treatment, and in the case of some emergency treatment, Neurological Surgery
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`patients sign assignments of benefits form provided to them by Neurological Surgery.
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`6
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`28.
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`In an emergency, Neurological Surgery is the intended beneficiary of assignments
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`of benefits that its patients who are Cigna Members sign in the hospital where the emergency
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`treatment occurs. The hospital assignments confer the Cigna Members' rights to bill Cigna for
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`the services, and to pursue and receive payment directly from Cigna, on all providers who treat
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`the Cigna Member while in the hospital, regardless of the providers' status as in-network or out-
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`of-network.
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`29.
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`Regardless of whether or not the applicable health plans at issue contain anti-
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`assignment clauses, Cigna has accepted and acknowledged the assignments of benefits at issue in
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`this lawsuit because, as detailed below, Cigna communicated with, paid, and otherwise dealt
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`directly with Neurological Surgery in connection with the health claims at issue. Such dealings
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`and course of conduct overrode and affected a waiver of any anti-assignment clause.
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`30.
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`By these assignments of benefits, contractual relationships were created by which
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`Cigna is obligated to reimburse Neurological Surgery directly for the services provided to the
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`Cigna Members.
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`31.
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`On the dates of service set forth in the annexed spreadsheet of medical claims in
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`issue, the Cigna Members listed therein presented to Neurological Surgery with health conditions
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`requiring Neurological Surgery to provide them with medically necessary health care services.
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`The spreadsheet of all medical claims at issue in this litigation is annexed hereto as Exhibit 1 and
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`incorporated herein by reference.1
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`1 Exhibit 1 is not being filed to protect patient privacy rights in accordance with, amongst other laws, the federal
`Health Insurance Portability and Accountability Act ("HIPAA"). An un-redacted version of the spreadsheet will be
`shared with Cigna and with the Court (upon request and filed under seal) upon the entry of an appropriate HIPAA
`protective order.
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`7
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`32.
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`The health care services provided by Neurological Surgery as set forth in Exhibit
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`1 were covered services under the applicable health plan documents.
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`33.
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`Cigna was aware at or around the times that Cigna Members received the health
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`care services at issue that Neurological Surgery provided these persons with covered health care
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`services.
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`34.
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`Cigna, as detailed below, engaged in communications or discussions with
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`Neurological Surgery acknowledging — or at the very least manifesting its awareness — that
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`Neurological Surgery was providing the Cigna Members with covered health care services.
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`35.
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`In all situations, Neurological Surgery was justified in providing medical services
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`to the Cigna Members, and in expecting payment, because it was mutually understood that Cigna
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`would reimburse Neurological Surgery for medically necessary services covered under the
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`applicable health plan documents.
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`36.
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`Given these facts and circumstances, Neurological Surgery reasonably expected
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`that Cigna would pay for these covered services at the rates and levels required under applicable
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`health plan documents, as well as federal and state law.
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`37.
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`By reason of the foregoing, express contracts or contracts implied-in-fact arose
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`between Cigna and Neurological Surgery (the "Contracts"), whereby Neurological Surgery
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`agreed to provide covered health care services to Cigna Members in exchange for Cigna paying
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`Neurological Surgery for those covered health care services at the rates and levels set forth under
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`the applicable health plan documents, as well as federal and state law.
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`8
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`38.
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`Based on Cigna's representations regarding payment to Neurological Surgery, and
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`the provisions of the federal Public Health Service Act and the New York Insurance and Public
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`Health Laws, Neurological Surgery provided the health care services as set forth in Exhibit 1
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`expecting to be promptly and properly paid for the services that were performed, medically
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`necessary, and billed appropriately.
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`39.
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`Unfortunately, this has not been the case.
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`40.
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`In many of the claims for health care services, Cigna has completely failed — in
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`some cases for several years — to pay anything for the medically necessary and covered treatment
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`provided by Neurological Surgery.
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`41.
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`And, in those cases in which Cigna paid something for the medically necessary
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`and covered treatment provided by Neurological Surgery to Cigna Members, the amount paid
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`was long delayed for no reasonable justification, and the amount paid was far below the required
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`rate.
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`42.
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`For months, and in some cases, years, Neurological Surgery has attempted to
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`enter into a meaningful dialog with Cigna to obtain prompt and proper payment for the
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`outstanding claims on Exhibit 1.
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`43.
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`Indeed, in all cases, the claims on the attached spreadsheet were subject to appeals
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`submitted by Neurological Surgery to Cigna, in an attempt to obtain appropriate payment for the
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`claim.
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`44.
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`Neurological Surgery's billing company routinely calls Cigna to follow up on
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`unpaid or underpaid claims, and follows all instructions provided by Cigna, whether verbally or
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`in writing, regarding the timing and form of appeals Neurological Surgery must take in order to
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`have denied or underpaid claims reviewed and paid at the appropriate rate.
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`45.
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`Despite this, Neurological Surgery's claims appeals submitted to Cigna have
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`either been improperly denied or have been ignored altogether.
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`46.
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`Additionally, Cigna has engaged in conduct that has rendered additional appeals
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`or attempted appeals by Neurological Surgery futile. Such conduct includes, without limitation:
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`(a) refusing to provide the specific reason or reasons for the denial or underpayment of claims;
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`(b) refusing to provide the specific plan provisions relied upon to support its denials or
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`underpayments; (c) refusing to provide the specific rule, guideline or protocol relied upon in
`
`making the decisions to deny or underpay claims; (d) refusing to describe any additional material
`
`or information necessary to perfect a claim, such as the appropriate diagnosis/treatment codes;
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`(e) refusing to notify the relevant parties that they are entitled to have, free of charge, all
`
`documents, records and other information relevant to the claims for benefits; (f) refusing to
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`provide a statement describing any voluntary appeals procedure available, or a description of all
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`required information to be given in connection with that appeals procedure; (g) refusing to
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`provide Neurological Surgery with the documents and information relevant to Cigna's denial of
`
`the claims; and (h) refusing to timely issue required notifications that the claims have been
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`denied or underpaid.
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`47.
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`Accordingly, Neurological Surgery's efforts to obtain proper payment for the
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`claims annexed hereto have largely fallen on deaf ears. All that the effort has produced are
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`vague letters and promises of proper payment at some uncertain point in the future, endless
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`requests and re-requests for documents supporting the claims, and vague allegations or
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`10
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`intimations regarding supposedly valid defenses to the outstanding claims, which never seem to
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`materialize.
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`48.
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`Accordingly, having exhausted all reasonable administrative remedies and
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`appeals — to the point where further administrative actions and appeals would be futile —
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`Neurological Surgery has been forced to commence this lawsuit.
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`FIRST CAUSE OF ACTION
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`49.
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`Neurological Surgery repeats and re-alleges the allegations of the preceding
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`paragraphs as if set forth at length herein.
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`50.
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`Neurological Surgery has standing to pursue claims under ERISA as the assignee
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`and authorized representative of its patients who are members or beneficiaries of Cigna's ERISA
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`health plans.
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`51.
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`As the assignee of its patients, Neurological Surgery is entitled to payment under
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`Cigna's ERISA health plans for the medical services provided to the patients by Neurological
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`Surgery.
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`52.
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`Upon information and belief, the Cigna ERISA health plans do not prohibit
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`patients from assigning their rights to benefits under the plans to Neurological Surgery, including
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`the right of direct payment of benefits under the plans to Neurological Surgery.
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`53. Moreover, even if some of the Cigna ERISA health plans prohibited the
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`assignment of benefits to Neurological Surgery, Cigna waived any purported anti-assignment
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`provisions, ratified the assignment of benefits to Neurological Surgery, and waived or is
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`estopped from using any purported anti-assignment provisions against Neurological Surgery, due
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`11
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`to Cigna's course of dealing with and statements to Neurological Surgery as out-of-network
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`providers.
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`54.
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`All of Cigna's ERISA health plans require payments of emergent and elective
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`medical expenses incurred by its members and beneficiaries up to the rate of Neurological
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`Surgery's full charges (less in-network patient responsibility amounts) for emergency/urgent care
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`and (less out-of-network patient responsibility amounts) for elective care.
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`55.
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`Neurological Surgery's incurred charges represent its usual and customary rates
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`for the treatment provided to Cigna's members or beneficiaries.
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`56.
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`Cigna breached the terms of its ERISA health plans by refusing to make out-of-
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`network payments for charges covered by the plans, in violation of ERISA § 502(a)(1)(B), 29
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`U.S.C. § 1132(a)(1)(B).
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`57.
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`These breaches include, among other things, (a) refusing to reimburse
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`Neurological Surgery for the medically necessarily services it provided to Cigna's members or
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`beneficiaries, as required by the Affordable Care Act; (b) refusing to reimburse Neurological
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`Surgery for the medically necessary services that it provided to Cigna's members or
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`beneficiaries, as required by 29 C.F.R. § 590.715-719A(b)(3)(i)(A)-(C); or (c) otherwise refusing
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`to reimburse Neurological Surgery the legally required amounts due under the plans for the
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`medically necessary services provided by the Neurological Surgery to Cigna's members or
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`beneficiaries.
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`58.
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`As a result of, among other acts, Cigna's numerous procedural and substantive
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`violations of ERISA and other federal statutes, any appeals are deemed exhausted or excused,
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`12
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`and Neurological Surgery is entitled to have this Court undertake a de novo review of the issues
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`raised in this Complaint.
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`59.
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`Under 29 U.S.C. § 1132(a)(1)(B), Neurological Surgery is entitled to recover
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`unpaid/underpaid benefits from Cigna. Neurological Surgery is also entitled to declaratory and
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`injunctive relief to enforce the terms of Cigna's ERISA health plans and to clarify its rights to
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`future benefits under such plans, as well as attorney's fees.
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`SECOND CAUSE OF ACTION
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`60.
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`Neurological Surgery repeats, reiterates, and re-alleges each and every allegation
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`contained above, as if more fully set forth at length herein.
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`61.
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`As assignees and authorized representatives of its patients' claims, Neurological
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`Surgery is entitled to receive protection under ERISA, including (a) a "full and fair review" of all
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`claims denied by Cigna; and (b) compliance by Cigna with applicable claims procedure
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`requirements.
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`62.
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`Based on all of the foregoing, Cigna's actions and inactions relating to the claims
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`at issue in this lawsuit are tantamount functionally to a denial of these claims.
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`63.
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`For denied claims pursuant to 29 U.S.C. § 1133, an ERISA plan must (a) provide
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`adequate notice in writing to any participant or beneficiary whose claim for benefits under the
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`plan has been denied, setting forth the specific reasons for such denial, written in a manner
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`calculated to be understood by the participant; and (b) afford a reasonable opportunity to any
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`participant whose claim for benefits has been denied for a full and fair review by the appropriate
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`named fiduciary of the decision denying the claim. 29 U.S.C. § 1133(1) and (2).
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`13
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`64.
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`ERISA regulations make clear that, in the case of post-service claims submitted
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`pursuant to group health plans, the required notification that the claim has been denied must be
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`issued within a reasonable period of time, but not later than 30 days after receipt of the claim,
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`unless the member or beneficiary is notified that, due to circumstances beyond the plan's control,
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`the plan requires an additional 15 days to issue a required denial notification. 29 C.F.R. § 2560-
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`503.1(f)(2)(iii)(B).
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`65.
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`Although Cigna is obligated to provide a "full and fair review" of denied and
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`underpaid claims pursuant to 29 U.S.C. § 1133, Cigna has failed to do so by, among other things:
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`(a) refusing to provide the specific reason or reasons for the denial or underpayment of claims;
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`(b) refusing to provide the specific plan provisions relied upon to support its denials or
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`underpayments; (c) refusing to provide the specific rule, guideline or protocol relied upon in
`
`making the decisions to deny or underpay claims; (d) refusing to describe any additional material
`
`or information necessary to perfect a claim, such as the appropriate diagnosis/treatment codes;
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`(e) refusing to notify the relevant parties that they are entitled to have, free of charge, all
`
`documents, records and other information relevant to the claims for benefits; (f) refusing to
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`provide a statement describing any voluntary appeals procedure available, or a description of all
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`required information to be given in connection with that procedure; (g) refusing to provide
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`Neurological Surgery with the documents and information relevant to Cigna's denial of the
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`claims; and (h) refusing to timely issue required notifications that the claims have been denied or
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`underpaid.
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`66.
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`By failing to comply with the ERISA claims procedure regulations, Cigna failed
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`to provide a reasonable claims procedure.
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`14
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`67.
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`Because Cigna has failed to comply with the substantive and procedure
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`requirements of ERISA, any administrative remedies are deemed exhausted pursuant to 29
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`C.F.R. § 2560.503-1(I) and 29 C.F.R. § 590.715-2719(b)(2)(ii)(F)(1).
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`68.
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`Exhaustion is also excused because it would be futile to pursue any administrative
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`remedies, because Cigna does not acknowledge any legitimate basis for its denials and thus
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`offers no meaningful administrative process for challenging its denials.
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`69.
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`Neurological Surgery has been harmed by Cigna's failure to provide a full and
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`fair review of appeals submitted and failure to comply with applicable claims procedure
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`regulations under ERISA. 29 U.S.C. § 1133.
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`70.
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`Neurological Surgery is entitled to relief under 29 U.S.C. § 1132(a)(3), including
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`declaratory and injunctive relief, to remedy Cigna's failures to provide a full and fair review, to
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`disclose information relevant to appeals, and to comply with applicable claim procedure
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`regulations.
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`THIRD CAUSE OF ACTION
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`71.
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`Neurological Surgery repeats and re-alleges the allegations of the preceding
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`paragraphs as if set forth at length herein.
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`72.
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`Through the assignments of benefits enumerated above — which have been
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`acknowledged and accepted by Cigna — Neurological Surgery obtained the right to enforce the
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`health plan contracts between Cigna and the Cigna Members listed above.
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`15
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`

`

`Case 1:21-cv-01549 Document 1 Filed 03/24/21 Page 16 of 22 PageID #: 16
`
`73.
`
`These health plan contracts, as detailed above, obligate Cigna to provide
`
`reimbursement for the medically necessary, covered health care services provided to the
`
`subscribers and/or members of those plans and their beneficiaries.
`
`74.
`
`Neurological Surgery, as enumerated above, provided medically necessary,
`
`covered health care services to the Cigna Members at issue.
`
`75.
`
`Neurological Surgery — as well as the Cigna Members at issue — have
`
`substantially and materially performed each and every obligation owed under these health plan
`
`contracts from their formation to date.
`
`76.
`
`Cigna has breached its obligations under these health plan contracts by failing to
`
`timely and properly pay Neurological Surgery for the medically necessary, covered services
`
`detailed above.
`
`77.
`
`Cigna's conduct was wanton, reckless, and affected the public.
`
`78.
`
`By reason of the foregoing, Neurological Surgery has been damaged in an amount
`
`to be determined at trial.
`
`79.
`
`By reason of the foregoing, Neurological Surgery is entitled to punitive damages
`
`in an amount to be determined at trial.
`
`FOURTH CAUSE OF ACTION
`
`80.
`
`Neurological Surgery repeats and re-alleges the allegations of the preceding
`
`paragraphs as if set forth at length herein.
`
`16
`
`

`

`Case 1:21-cv-01549 Document 1 Filed 03/24/21 Page 17 of 22 PageID #: 17
`
`81.
`
`Implied-in-fact contracts arose between Cigna and Neurological Surgery
`
`regarding the provision of, and corresponding payment for, the medically necessary, covered
`
`health care listed above that were provided to Cigna Members based on the parties' course of
`
`dealings and pattern of conduct.
`
`82.
`
`Specifically, in many cases, Cigna was aware at, before, or during the time the
`
`services were rendered — because of pre-authorization, pre-certification, or other requirements —
`
`that Neurological Surgery was providing the medically necessary, covered health care services at
`
`issue.
`
`83.
`
`As a result of the facts and circumstances surrounding the acts and conduct of the
`
`parties, there was a meeting of minds.
`
`84.
`
`This meeting of the minds constituted an implied-in-fact agreement.
`
`85.
`
`Neurological Surgery has substantially and materially performed each and every
`
`obligation owed under these implied-in-fact contracts.
`
`86.
`
`Cigna, as detailed above, has breached its obligations under these contracts by
`
`failing to timely and properly pay Neurological Surgery for the medically necessary health care
`
`services at issue that Neurological Surgery provided to the Cigna Members at issue.
`
`87.
`
`Cigna's conduct was wanton, reckless, and affected the public.
`
`88.
`
`By reason of the foregoing, Cigna has been damaged in an amount to be
`
`determined at trial.
`
`17
`
`

`

`Case 1:21-cv-01549 Document 1 Filed 03/24/21 Page 18 of 22 PageID #: 18
`
`89.
`
`By reason of the foregoing, Neurological Surgery is entitled to punitive damages
`
`in an amount to be determined at trial.
`
`FIFTH CAUSE OF ACTION
`
`90.
`
`Neurological Surgery repeats and re-alleges the allegations of the preceding
`
`paragraphs as if set forth at length herein.
`
`91.
`
`Neurological Surgery was entitled to be paid at a reasonable rate by Cigna for the
`
`medically necessary, covered health care services listed above to the Cigna Members at issue.
`
`92.
`
`Cigna improperly and without justification failed to timely and properly pay
`
`Neurological Surgery for the medically necessary and covered services it provided, as
`
`enumerated above.
`
`93.
`
`Cigna was unjustly enriched by not paying Neurological Surgery at a reasonable
`
`rate, or in some cases at all.
`
`94.
`
`This enrichment was at Neurological Surgery's expense.
`
`95.
`
`Given all of the facts and circumstances, Cigna must return this unjust benefit to
`
`Neurological Surgery.
`
`96.
`
`By reason of the foregoing, Neurological Surgery has been damaged in an amount
`
`to be determined at trial.
`
`97.
`
`By reason of the foregoing, Neurological Surgery is entitled to punitive damages
`
`in an amount to be determined at trial.
`
`18
`
`

`

`Case 1:21-cv-01549 Document 1 Filed 03/24/21 Page 19 of 22 PageID #: 19
`
`SIXTH CAUSE OF ACTION
`
`98.
`
`Neurological Surgery repeats and re-alleges the allegations of the preceding
`
`paragraphs as if set forth at length herein.
`
`99.
`
`Neurological Surgery has a valid contractual relationship with each of the Cigna
`
`Members listed above, arising from: (a) Neurological Surgery's agreement to provide medical
`
`treatment and the Cigna Members, and the Cigna Members' corresponding agreement to pay
`
`Neurological Surgery for those services; or (b) each authorization and assignment that
`
`Neurological Surgery received from the these Cigna Members allowing it to receive payment
`
`directly from Cigna.
`
`100. Cigna knew of these contractual or business relationships and maliciously,
`
`intentionally, and without justification interfered with them by, among other things:
`
`a)
`
`b)
`
`c)
`
`d)
`
`e)
`
`issuing blanket medical necessity denials on claims for medically necessary,
`covered health care services provided to Cigna Members without actually
`reviewing the medical necessity of the services rendered;
`
`issuing medical necessity denials on claims for services provided to Cigna
`Members by Neurological Surgery when such services were known by Cigna to
`be entirely medically necessary;
`
`issuing checks and payments directly to patients in a manner designed to
`encourage Cigna Members not to honor their obligations to Neurological Surgery;
`
`issuing denials on claims for services provided to Cigna Members by
`Neurological Surgery in such a way as to avoid external appeal requirements
`imposed by the New York Public Health Law and New York Insurance Law; and
`
`deliberately avoiding, delaying, and systematically denying reimbursement to
`Neurological Surgery for medically necessary services provided to Cigna
`Members without explanation.
`
`101. By reason of the foregoing, Neurological Surgery has been damaged in an amount
`
`to be determined at trial.
`
`19
`
`

`

`Case 1:21-cv-01549 Document 1 Filed 03/24/21 Page 20 of 22 PageID #: 20
`
`102. By reason of the foregoing, Neurolog

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