On Wednesday in the Eastern District of Pennsylvania, Genomind Inc. filed a complaint against UnitedHealth Group and its subsidiaries, alleging that the defendants misrepresented which of the plaintiffs’ services they would cover and violated the Employee Retirement Income Security Act (ERISA).
As a response to the growing “burden of mental health treatment” in the United States, Genomind’s Professional PGx Express product provides testing of saliva that can identify whether a patient has genetic variations that may make certain psychiatric medications less effective or increase the risk of side effects, the complaint explains. More than 15,000 practitioners have ordered Genomind’s tests, with about 70% reordering them, for more than 265,000 patients, according to the complaint.
As the “largest administrator of behavioral health claims” in the country, UnitedHealth’s subsidiary United Behavioral Health serves more than 43 million people, the complaint states. A coverage change by United announced Aug. 1, 2019, and effective Oct. 1, 2019, that signaled it would now cover the Genomind Assay product prompted the plaintiff to begin working with United to ensure that Genomind could receive compensation for its submitted claims. Ensuring this required Genomind to develop a new test that met United’s requirements; United recognized that the testing only was “proven and medically necessary for antidepressants and antipsychotics medication” when the individual “has a diagnosis of major depressive disorder or anxiety” and “has failed at least one prior medication to treat their condition” and when the product tests “no more than 15 relevant genes,” the complaint states.
The plaintiff argued that it worked to completely overhaul its test — now deemed the Core 15 Test — to fit these requirements, “only to have United withhold such payment without reasonable basis and then mislead about why claims were not being paid.” Genomind cited communications with United officials that caused Genomind to believe its newly developed test would be covered as an out-of-network service, such as an email from United’s Senior Director of Oncology and Genetics, Dr. Jennifer Malin, that stated to another copied official, “This email is to introduce you to Genomind who have a test that our PGx policy will now cover as of 10/1.” From this purported conduct, among other instances, the plaintiff alleged breach of implied-in-fact contract and negligent misrepresentation.
Further, the plaintiff alleged a violation of ERISA, given the terms of those insured under United plans governed by ERISA, along with promissory estoppel, quantum meruit, and unjust enrichment.
Requests by the plaintiff include compensatory damages, punitive damages, benefits pursuant to the United plan in question and clarification of insureds’ rights, and attorney’s fees, among other reasonable relief.
The plaintiff is represented by the Martin Law Firm and Zuckerman Spaeder.
