United States of America, United States District Court for the District of New Jersey, 18 May 2022, Open MRI and Imaging v. Cigna Health and Life Insurance Co.
Case overview
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Deciding body (English)
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Outcome of the decision
General Summary
The plaintiff was a medical practice that served patients insured by the defendant. The plaintiff claimed that it had submitted invoices to the defendant for Covid-19 tests administered to its insured patients, but the defendant had declined to pay. The plaintiff then filed an action on behalf of those patients for violations of the Employee Retirement Income Security Act. The defendant filed a motion to dismiss for failure to state a claim. The Court analyzed both parties’ arguments and denied the motion to dismiss on grounds that the interpretation of the statutory law led to the conclusion that the Plaintiff had sufficiently stated a claim based on the Employee Retirement Income Security Act and the Families First Act.
Facts of the case
The Plaintiff was a medical practice that provided Covid-19 testing to the Defendant’s insured patients, among other medical services. The Plaintiff submitted invoices to the Defendant for Covid-19 tests, totaling at least $1,522,644, claiming that the patients receiving these tests did so pursuant to their medical insurance plans. However, the Defendant declined to pay the Plaintiff for these services because the services were purportedly (1) not rendered as billed, (2) did not match the services billed, or (3) because the billing was duplicative. The Plaintiff argued these reasons were invalid and, on behalf of the patients, filed the claim against Defendant.
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Claimant(s)
Private individualDefendant(s)
Private individual
Type of procedure
Reasoning of the deciding body
The Court analyzed the arguments of the Plaintiff and the Defendant and reasoned that:
- The Facial-plausibility standard was met when the plaintiff plead factual content that allowed the Court to draw the reasonable inference that the defendant was liable for the misconduct alleged.
- The Employee Retirement Income Security Act provided a uniform regulatory regime over employee benefit plans, including health insurance plans and provided that “[a] civil action may be brought … by a participant or beneficiary ... to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan.”
- Federal law required health insurers to cover Covid-19 testing and this legal obligation was incorporated as a term of the plan, enforceable by the Employee Retirement Income Security Act.
- The Families First Act stated that “group health plans” “shall provide coverage” for Covid-19 testing, and that the “group health plan” had the same meaning as in the Employee Retirement Income Security Act. By using the term “group health plan” Congress clearly conveyed that it was imposing obligations on the plans, not just on regulated entities in some more general sense.
- Finally, Congress mandated that health insurance plans cover Covid-19 testing, raising it to the status of a benefit of those plans. Congress also allowed the insured to sue for benefits due to them. It therefore stood to reason that the insured could sue under the Employee Retirement Income Security Act when an insurer denied coverage for Covid-19 testing.
Conclusions of the deciding body
The Court concluded that the Defendant’s claims did not stand in the face of statutory law and the Plaintiff had sufficiently shown their claim. The motion to dismiss was thus denied.
