Case 4:21-cv-04200 Document 1-3 Filed on 12/28/21 in TXSD Page 1 of 6
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`EXHIBIT A
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`EXHIBIT A
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`CAUSE NO.
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`21-11-15225
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`Received and E-Filed for Rem
`1 1/1/2021 6:37 Pi
`Melisa Miller, District Clei
`Montgomery County, TexE
`Deputy Clerk, Chelsey Lyr
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`TEXIENNE PHYSICIANS MEDICAL
`ASSOCIATION, PLLC
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`ss
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`IN THE DISTRICT COURT OF
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`V.
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`CIGNA HEALTHCARE OF TEXAS, §
`INC
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`MONTGOMERY COUNTY, TEXAS
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`Montgomery County - 284th Judicial District Court
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`JUDICIAL DISTRICT
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`PLAINTIFF'S ORIGINAL PETITION
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`TO THE HONORABLE JUDGE OF SAID COURT:
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`COME NOW, Texienne Physicians Medical Association, PLLC ("TPMA") (hereinafter
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`referred to collectively as "Plaintiff' or "Texienne") and files this Original Petition against Cigna
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`Healthcare of Texas, Inc. ("Cigna") and in support thereof shows as follows:
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`I. PARTIES
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`1.
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`Texienne Physicians Medical Association, PLLC ("TPMA") is a Texas
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`professional limited liability company with principal offices at 9303 Pinecroft Dr., Ste 280,
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`Montgomery County, TX.
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`2.
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`Defendant Cigna Healthcare of Texas, Inc.is a Texas corporation with its principal
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`place of business at 900 Cottage Grove Rd., Hartford, CT 06125. It may be served via its registered
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`agent, CT Corporation System, at 1999 Bryan St., Ste. 900, Dallas, Texas 75201.
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`II. JURISDICTION AND VENUE
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`3.
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`This Court has jurisdiction over this matter because the amount in controversy
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`exceeds its minimum jurisdictional requirements. Venue is proper under Section 15.002 of the
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`Texas Civil Practice & Remedies Code because all or a substantial part of the events or omissions
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`giving rise to the claims occurred in Montgomery County, Texas and contractual obligations of
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`both Plaintiff and Defendant was to be performed in substantial part in Montgomery County. This
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`Court has general and specific personal jurisdiction over Cigna because it is domiciled in Texas.
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`Venue is proper under ERISA as Cigna's breach of its obligation to pay sTPMA occurred in
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`Montgomery County, Texas.
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`4.
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`5.
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`Plaintiffs request that the Court order a Level 2 Discovery Control Plan.
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`Pursuant to Rule 47 of the Texas Rules of Civil Procedure, Plaintiffs seek damages
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`within the jurisdictional limits of this Court, including monetary relief between $250,000 and
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`$1,000,000.
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`IV. FACTS
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`6.
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`TPMA is a large physician group practice with numerous offices in Texas. TPMA
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`began operations as a Physician Group in late 2016. From inception, TPMA provided services to
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`patients insured by Cigna and obtained assignments of these insurance benefits from those patients.
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`TPMA therefore has standing to assert the right of those patients to payments under those policies.
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`TPMA also provided services to patients insured by employee health benefit plans administered
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`by Cigna under contract with the sponsor of those plans. TPMA obtained assignments of benefits
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`from those patients as well and therefore has standing to assert the right of those patients to
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`payments under the various employee health benefit plans against the plans and, where applicable,
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`against Cigna.
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`7.
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`TPMA has fully complied with its obligations to receive payment from Cigna and
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`timely submitted clean claims for reimbursement by Cigna. However, Cigna has failed to pay
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`TPMA for clean claims in excess of $250,00.00. Certain of these claims were for in-network
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`services provided to Cigna's subscribers.
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`V. CLAIMS AGAINST DEFENDANT
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`Breach of Contract
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`8.
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`Plaintiff incorporates the foregoing paragraphs as if fully set forth here.
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`2
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`9.
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`Cigna was contractually obligated to pay Plaintiff for the healthcare services
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`provided to Cigna's subscribers.
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`10.
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`Plaintiff fully performed under the contracts:
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`1 1.
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`Cigna materially breached its statutory and contractual obligations by improperly
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`denying Plaintiffs' "clean claims" for covered medical services.
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`12.
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`For in-network claims, Cigna was also statutorily obligated to pay the "clean
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`claims" submitted by Plaintiff pursuant to § 843.342 of the Texas Insurance Code.
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`13.
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`Because Cigna failed to timely pay Plaintiff's claims, Plaintiff is entitled to
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`statutory penalties and interest under Texas Insurance Code § 843.336, et seg.
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`14.
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`Plaintiff has suffered damages as a result of Cigna's breaches and is entitled to
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`recover it reasonable and necessary attorney's fees incurred to prosecute this matter.
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`Liability under ERISA
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`15.
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`Plaintiff incorporates the foregoing paragraphs as if fully set forth here.
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`16.
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`Cigna also administered one or more health plans subject to the U.S. Employee
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`Retirement Income Security Act of 1974 ("ERISA"). Under ERISA § 502(a)(1)(B) (29 U.S.C. §
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`1 132(a)(1)(B)), a health plan participant or beneficiary may bring a civil action to recover benefits
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`due under the terms of the plan and to enforce rights under the terms of the plan.
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`17.
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`Plaintiff obtained assignments of benefits from patients insured by Cigna and
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`TPMA may sue derivatively to enforce the benefits due under each insured's plan.
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`18.
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`For in-network claims under policies or plans governed by ERISA, Cigna failed to
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`properly pay the benefits due under the terms of the respective plans. The Physician Group
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`Agreement and the Provider Agreement govern the claims submitted to Cigna for services
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`provided to ERISA beneficiaries. Cigna was contractually obligated to pay benefits at a specified
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`3
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`reimbursement rate for the reasonable and customary charges, as set forth in each member's plan
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`and the Provider and Physician Group Agreements.
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`19.
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`Cigna failed to administer the plan for the benefit of the plan beneficiaries and is
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`directly liable to pay the claims.
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`20.
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`Cigna failed to properly adjudicate the claims and to provide proper written notice
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`of how it adjudicated the claims. Therefore, all administrative remedies are deemed to be
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`exhausted.
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`21.
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`Because Cigna failed to meet its duties under ERISA, the Court may award TPMA
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`attorney fees Pursuant to 29 U.S.C. 1132(g)(1).
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`VI. DAMAGES
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`22.
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`Each of the unlawful acts alleged above has proximately caused damages to
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`Plaintiff. Plaintiff suffered and will continue to suffer in the future, actual damages, direct and
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`consequential, including without limitation lost profits in the past and in the future, and damage to
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`goodwill.
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`VII. CONDITIONS PRECEDENT
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`23.
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`All conditions precedent to Plaintiff's recovery have been performed or have
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`occurred under contract and under ERISA.
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`IX. PRAYER
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`24.
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`Plaintiff prays that Cigna be cited to appear and answer herein, and that upon final
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`trial, the Plaintiff recover the following from the Defendant:
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`• All actual damages suffered by Plaintiff, an amount which is excess of the
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`minimum jurisdictional limit of the Court;
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`• Costs of suit, pre-judgment and post judgment interest in the maximum amount
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`allowed by law;
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`4
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`• Statutory penalties and interest;
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`• Attorney's fees; and
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`• Any and all other relief Plaintiff may be entitled to at law or in equity.
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`Respectfully submitted,
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`SEILER MITBY, PLLC
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`/s/ Steven J Mitbv
`Steven J. Mitby
`State Bar No. 24037123
`smitby@seilermitby.com
`Kelly D. Clark
`State Bar No. 24094781
`kclark@seilermtiby.com
`Michael K. Barnhart
`State Bar No.
`mbamhart@seilermitby.corn
`2700 Research Forest Drive, Suite 100
`The Woodlands, Texas 77381
`(281) 419-7770
`(281) 419-7791 — Telecopier
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`ATTORNEYS FOR PLAINTIFF
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`5
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