Managed Care Litigation Update Volume 157: July 31, 2020

• Jurisdiction: United States,Federal
• Publication year: 2020
• Citation: Vol. 157

NEWSWORTHY

District court dismisses recoupment effort of CIGNA alleging fraudulent billing scheme of OON laboratories with joint ownership. Cigna alleged fraudulent (1) fee forgiveness, (2) unnecessary testing, and (3) unbundling, but the court ruled a 3-year limitations period barred the claims. Connecticut General Life Insurance Co., et al., v. Biohealth Laboratories, Inc., et al., USDC D. Conn., No. 3:19-cv-1324-JCF, (Doc. 47, filed Jun. 17, 2020). Notice of Appeal filed.

D.C. Circuit affirms dismissal of challenge to 2018 rule permitting 1-year terms of short-term limited duration ("STLDI") plans, with the option of renewals for a total term of up to three year. Ass'n for Community Affiliated Plans, et al. v. U.S. Dep't of the Treasury, USAP DC Cir, No. 19-5212, (Doc. 1852209, filed Jul. 17, 2020).

Third Circuit revives promissory estoppel and breach of contract claims of plastic surgeon, holding that Section 514(a) of ERISA does not preempt two separate claims as to an OON provider who allegedly obtained pre-service authorizations and agreement to be reimbursed at a "reasonable amount" and the "highest in-network level," respectively. Plastic Surgery Center, P.A., v. Aetna Life Insurance Company, USAC 3d Cir., No. 18-3556, (Doc. 83, filed Jul. 17, 2020). See also MCLU Vol. 96.

RECENTLY FILED ACTIONS

Brooks Welch, et al. v. Cigna Health and Life Insurance Company, et al., U.S.D.C. E.D. PA, Doc. No. 2:20-cv-3525-AB, (filed Jul. 17, 2020). Removed action in which member seeks benefits associated with claims in the amount of $9,113.00, $39,106.64, and $27,818.41 associated with the treatment of neuroendocrine cancer. Plaintiff alleges his ERISA coverage was terminated without his knowledge due to his allegedly mistaken eligibility for Medicare Part B.

Bernard Trainor, et al. v. [ ], United Healthcare Core, U.S.D.C. D. UT, Doc. No. 4:20-cv-76-DN-PK, (filed Jul. 17, 2020). Parents seek ERISA benefits on behalf of daughter associated with in patient mental health treatment at Solacium Sunrise. Claim was denied as not medically necessary and upheld on appeal and independent review.

Paragon Infusion Care, Inc. v. Blue Cross Blue Shield of North Carolina, et al., U.S.D.C. E.D. NC, Doc. No. 4:20-cv-140-BO, (filed Jul. 20, 2020). Specialty pharmacy alleges seeks benefits from government-sponsored plan associated with multiple fills of Adynovate. Total billed charges were $538,401. Plaintiff asserts it was assured Adynovate was a covered benefit from June 7...