C. v. Cigna Health and Life Insurance

On June 28th, 2021, Kelly C., individually and on behalf of K.B. a minor, (“Plaintiffs”) represented by Brian S. King filed a labor - employee benefit lawsuit against Cigna Health and Life Insurance Company, (“Defendant”) for allegedly wrongfully denying insurance coverage to the Plaintiffs. This case was filed in the U.S. District Court for the District of Utah with Judge Cecilia M. Romero presiding. 

In the complaint, the Plaintiff alleged that “K.B. was adopted from an orphanage in Russia around the time that she was a year old. When K.B. was about five years old, she began seeing a therapist and was diagnosed with attention deficit disorder. When she was in the eighth grade, she was diagnosed with Reactive Attachment Disorder. K.B.’s therapist recommended that she be placed in a residential treatment program . . . K.B. sought out risky relationships, often with older men, and also started abusing alcohol to the point of blacking out. In an effort to provide K.B. with the support that she needed, she began attending an outdoor behavioral health program called Evoke.”

The Plaintiff also alleged that “Following her discharge from Evoke, K.B. was admitted to New Haven on November 27, 2018. In a letter dated December 24, 2018, Cigna denied payment for K.B.’s treatment. The letter gave the following justification for denying payment: Insufficient clinical information has been provided by the facility to support the medical necessity for continued stay at Residential Mental Health Treatment for Children and Adolescents from 12/21/2018 forward. Therefore, this request is denied.”

The Plaintiff also alleged that “Kelly reminded Cigna of its obligations under ERISA including taking into account all of the information she provided, providing the information she needed to perfect the appeal, acting in K.B.’s best interest, and utilizing an appropriately qualified reviewer.”

Further, “Kelly listed the Plan’s requirements for admission to a residential treatment center as well as the definition of a medically necessary service. She stated that since K.B.’s “treatment is medically necessary according to Cigna criteria, Cigna’s denial has no basis.” She requested that Cigna process the appeal in compliance with MHPAEA. In a letter dated July 9, 2019. Cigna upheld the denial of payment for K.B.’s treatment.”

Plaintiff even further alleged that “The denial of benefits for K.B.’s treatment was a breach of contract and caused Kelly to incur medical expenses that should have been paid by the Plan in an amount totaling over $90,000.”

There are two claims for relief laid down by the Plaintiff. The first for a Claim for Recovery of Benefits Under 29 U.S.C. §1132(a)(1)(B)). The second claim is for alleged violations of MHPAEA Under 29 U.S.C. §1132(a)(3)).

In the prayer for relief, the Plaintiffs request the Court to order a judgment in the total amount that is owed for K.B.’s medically necessary treatment at New Haven under the terms of the Plan, plus pre and post-judgment interest to the date of payment; appropriate equitable relief under 29 U.S.C. §1132(a)(3) as outlined in Plaintiffs’ Second Cause of Action; attorney fees and costs incurred pursuant to 29 U.S.C. §1132(g); and for such further relief as the Court deems just and proper.

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