Plaintiffs Taylor B. Theunissen, MD, LLC and the Sadeghi Center for Plastic Surgery, LLC filed suit on Tuesday in the Eastern District of Louisiana against defendant United Healthcare of Louisiana, Inc. The complaint, which was filed by the plaintiffs on behalf of their patient N.T., alleges that United failed to pay preauthorized claims in violation of ERISA.
Patient N.T. was designated as a beneficiary under the employee health benefit plan (the plan) administered by the defendant, the complaint says. When the plaintiff was diagnosed with breast cancer and had a bilateral mastectomy and breast reconstruction surgery, the reconstruction required subsequent revision involving deep inferior epigastric perforator flaps, or DIEP flaps, per the complaint.
According to the complaint, DIEP flap procedures are covered by the plan, which specifies that benefits are provided “for reconstructive procedures [including] breast reconstruction following a mastectomy and reconstruction of the non-affected breast to achieve symmetry.”
Prior to the patient’s surgeries, the plaintiffs say they obtained preauthorization from the defendant, who stated that they had determined the treatment to be medically necessary. This preauthorization allegedly led the plaintiffs to conclude that they “would perform the first surgery and United would pay them the reasonable and customary charges incurred.”
Following the surgery, the plaintiffs submitted claims to the defendant, pe rthe complaint. United rejected the claims in part, stating that “during adjudication of out-of-network claims, our system refers to the FH Benchmark database and automatically applies the amount reported at the plan’s selected percentile for your geographic area for eligible claims.” The defendant’s reasoning left the patient with an outstanding balance of over a hundred thousand dollars.
Patient N.T. required additional surgeries that were preauthorized by the defendant, but when the plaintiffs submitted the claims, United either failed to pay them or partially paid them, according to the complaint.
The plaintiffs assert that the defendant has repeatedly denied claims and that “the minimal payments that were made are clearly insufficient and contrary to the Plan.” United continued to deny its liability even after the plaintiffs filed multiple appeals.
The complaint concludes that the defendant’s refusals to make payments are in violation of the Employee Retirement Income Security Act, or ERISA. The suit cites a claim for benefits, breach of contract, and detrimental reliance. The plaintiffs are seeking a declaration of the defendant’s violations, a direction requiring that the defendant fulfill its payment obligations, damages, prejudgment interest, litigation fees, and any other equitable relief deemed necessary by the Court.
The plaintiff is represented by Murray Law Inc.