Cigna Sued by Hospital over Reimbursement Denial

On Thursday, plaintiffs MISUB (SFH), Inc. doing business as Saint Francis Hospital (Saint Francis) and Saint Francis Hospital Bartlett, Inc. (Hospitals) filed a complaint in the Western District of Tennessee against Cigna Health and Life Insurance Company for breach of contract regarding Cigna’s refusal to reimburse the appropriate cost of emergency medical services for Cigna members.

Per the complaint, federal and Tennessee law both require hospitals offering emergency services to treat all patients who center an emergency room, regardless of insurance coverage.

The defendant, and other insurers are required by law to ensure their members receive emergency care when necessary. Cigna has agreed that the plaintiffs’ claims where reasonable and the medical treatments where necessary, however Cigna disagreed over the amount they are being asked to pay. Cigna is only disputing reimbursement for non-participating claims, according to the filing.  The non-participating claims all  involve  services  provided to Cigna members who are enrolled in health insurance plans outside of the Hospitals insurance. Therefore,  no contracts specify the reimbursement rate for the non-participating claims.

According to the Hospitals, since January 1, 2019, Cigna has underpaid the Hospitals’ claims for thousands of Cigna member’s services.  The underpayments allegedly equate to millions of dollars in lost fees for the plaintiffs.

Per the plaintiffs, Cigna had an agreement with the hospitals to reimburse out-of-network services at 75% of the hospitals’ billed charges, however as of January 1, 2019, Cigna has reimbursed less than half of that amount.

The plaintiffs are represented by Gideon, Essary, Tardio & Carter PLC. The instant action is brought under the Emergency Medical Treatment and Labor Act for unjust enrichment, quantum meruit, and breach of implied-in-fact contract.

The plaintiffs are seeking declaratory judgment in their favor; for damages in an amount representing the difference between what the defendant paid and what the plaintiffs deem fair.