A complaint was filed Monday in the District of New Jersey against Cigna Health and Life Insurance Company, or Cigna. The complaint was filed by Dr. John D. Lipani, M.D., who is acting as an assignee, authorized representative, and attorney-in-fact of his patient, S.L. It alleges that Cigna engaged in the unlawful denial of benefits to their beneficiary, S.L., after claims were submitted for a pre-approved surgery.
Dr. Lipani, according to the complaint, is a neurosurgeon who specializes in both minimally invasive and non-invasive brain and spinal surgery; he owns and operates Princeton Neurological Surgery, P.C. (PNS), which specializes in “brain tumor treatment, treatment of intracranial conditions, complex brain surgery, brain tumor surgery, complex spine surgery, and minimally invasive surgery.” The defendant, the complaint says, administers healthcare plans to certain patients, like S.L., and provides them with benefits as a result of the commercial health plans.
The patient, S.L., came to Dr. Lipani with complaints of “unremitting mechanical low back pain, in addition to neurogenic claudication.” After reviewing her history, medical records, and imaging studies, Dr. Lipani diagnosed S.L. with degenerative disc disease, endplate sclerosis, stenosis, bilateral facet hypertrophy, and pseudoarthrosis. These diagnoses warranted the performing of a lumbar spine fusion, which Cigna approved prior to the procedure.
The decision to abort the surgery was not made until after S.L. had been placed under general anesthesia, which led PNS to submit medical bills directly to her insurer, Cigna, for the services rendered. Cigna denied this bill and a subsequent modified bill, claiming that the operative report submitted “does not support procedures performed as billed.” An appeal by Dr. Lipani was denied by Cigna with identical reasoning. The plaintiff explains that these denials left him with little option but to pursue a legal remedy.
Dr. Lipani is charging Cigna with violations of their own plan and denials that were “arbitrary, capricious, and manifestly mistaken.” Dr. Lipani seeks a declaration of the violations, an order directing payment in full, pre-judgment interest, litigation fees, and other relief deemed necessary by the court.
The plaintiff is represented by Buttaci, Leardi & Werner, LLC.