Neurological Surgery Practice of Long Island PLLC (Neurological Surgery) sued Cigna Health and Life Insurance Company and Connecticut General Life Insurance Company (together, Cigna) on Wednesday for its failure to reimburse Neurological Surgery for services the medical practice provided to members of Cigna’s health plans. The Eastern District of New York complaint states causes of action under the Employee Retirement Income Security Act of 1974 (ERISA) and for breach of contract.
According to the filing, Neurological Surgery is the largest private neurosurgery practice on Long Island and in the tristate area. Cigna, the plaintiffs alleges, is one of the largest health insurers in the country.
The complaint explains that Neurological Surgery is not a member of Cigna’s “provider network” and is therefore an “out-of-network” provider. Upon information and belief, the filing states, a substantial proportion of Cigna’s members can seek medically necessary treatment from out-of-network providers like the plaintiff. When members do, Cigna is purportedly obligated to reimburse them at the usual, customary, and reasonable cost of the services rendered, less any co-payment, co-insurance, member out-of-pocket, or deductible amount.
Neurological Surgery states that it routinely receives authorizations from Cigna to provide services to the insurer’s members. In a medical emergency, the plaintiff explains, it becomes the intended beneficiary through a contract the Cigna member patient signs in the hospital, where the emergency treatment occurs, irrespective of Neurological Surgery’s status as an out-of-network provider.
Yet, the filing claims, Cigna has failed, in some cases for several years, to pay for treatment performed by Neurological Surgery. Allegedly, and as to those claims which Cigna has paid for, “the amount paid was long delayed for no reasonable justification, and the amount paid was far below the required rate.”
The complaint claims that Cigna breached the terms of its ERISA health plans by refusing to make these out-of-network payments and by failing to provide a “full and fair review” of denied and underpaid claims. The plaintiff seeks declaratory and injunctive relief, compensatory and punitive damages, interest, and its attorneys’ fees and litigation costs.
Neurological Surgery is represented by Harris Beach, PLLC.
