Insurers Vie for Dismissal of Reimbursement Scheme Claims

The defendants of a case filed in April 2020, Cigna Behavior Health, Inc., and Multiplan, Inc., have responded to the initial complaint against them which alleged their involvement in a reimbursement scheme. The complaint was filed in the Northern District of California by a plaintiff known as R.J., who filed suit as the representative of her son and all others similarly situated.

The complaint explained that R.J. and her son were covered under Cigna’s insurance plan, for which they paid a higher premium for a specific privilege that allowed them to choose out-of-network healthcare providers. The son, the complaint said, received treatment for his mental health and substance use disorders from out-of-network providers who were “licensed, accredited, treatment providers.” Despite their plan allowing this type of treatment, Cigna allegedly denied their coverage claims all while “reaping large profits from his [SJ’s] supposedly premier, gold-plated plan.”

The plaintiff claimed that the defendants conspired in a reimbursement scheme. They argued that Cigna “contracted with Viant to create an illegal enterprise to underpay out-of-network benefits, shield Cigna form the providers and insureds they cheated, and create impenetrable, systemic, administrative barriers to circumvent rights protected by federal laws.”

The complaint detailed that “for years, Cigna and Viant have systematically failed to properly price the claims according to UCR [usual and customary rates] and have systematically concealed this failure through misrepresentations about pricing and payment methods.”

Following the filing of the complaint, both Cigna and Multiplan requested for the plaintiff’s first amended class complaint to be dismissed in its entirety. Multiplan asserted that the claims should be dismissed because the “plaintiffs’ opposition adds nothing to remedy the fact that the first amended complaint is inadequately pled,” and that they have failed to “properly plead their claims for equitable relief.” Cigna subsequently filed a response stating that the plaintiffs’ “RICO claims and all of the Plaintiff LW’s claims should be dismissed with prejudice.”

The plaintiff is represented by Napoli Shkolnik and DL Law Group. The defendants are represented by McDermott Will & Emery, Phelps Dunbar, and Sheppard, Mullin, Richter & Hampton.