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Law360 (February 25, 2021, 3:47 PM EST) -- Cigna Health and Life Insurance Co. has called on a New Jersey federal court to end a radiology lab's suit alleging it improperly refused to pay nearly $400,000 for COVID-19 services, saying the business failed to provide the "core information" needed to back up its ERISA claim.
In urging the court to toss an amended complaint, the insurer on Wednesday said Open MRI and Imaging of RP Vestibular Diagnostics PA has not identified the patients behind the denied payments and whether the lab has been assigned their rights under their benefit plans.
The lab's failure to specify the plans at issue and the provisions in those plans that Cigna allegedly violated is "particularly problematic," Cigna said in its brief, as it is well settled in New Jersey federal court that "a plaintiff cannot state an [Employee Retirement Income Security Act] benefits claim without identifying the plan provision that was breached."
"There is no articulation of a plan term that, if properly applied, would lead to plaintiff gaining the relief it seeks," Cigna said. "And, if any of this information did appear, there is no allegation as to how this medical provider would have standing to assert the rights of its patients under their respective employee benefit plans."
"The amended complaint relies purely on bald assumptions that plaintiff is entitled to relief under ERISA and leaves the matter there," the insurer added.
The lab, which is located in Rochelle Park, New Jersey, filed its initial suit on Aug. 12 and then the amended complaint on Dec. 11, asserting a violation of ERISA and claims of unjust enrichment and quantum meruit.
The amended complaint alleged that between last February and July, the lab sent invoices totaling $398,665 to Cigna for "diagnostic services and treatment related to coronavirus," but the insurer denied making the payments.
The explanations provided by Cigna included "unelaborated denials that the services were rendered as billed, or matched the services billed, as well as the occasional contention that the billing was duplicative," the complaint said.
"The grounds for rejecting plaintiff's claims were, upon information and belief, false and invalid," the complaint said.
But Cigna argued Wednesday that the complaint does not include allegations explaining why its reasons for denying the claims — "that the services were not actually provided as billed or billed incorrectly" — are incorrect. The company said it also appears that many of the services cited by the lab "relate to treatment that preceded the COVID-19 pandemic."
The insurer further blasted the lab's invocation of the Families First Coronavirus Response Act and the Coronavirus Aid, Relief and Economic Security Act. The lab alleged in its complaint that Cigna violated those federal statutes and is "therefore liable" pursuant to ERISA.
The FFCRA and the CARES Act, however, do not provide "a private right of action," and a violation of either statute is "not one of the very specific causes of action enumerated in ERISA," Cigna argued.
"There is no justification, however, for plaintiff to attempt such an 'end-run' around the statutory limitations of the FFCRA or the CARES Act," Cigna said. "Until such time that Congress explicitly determines parties such as plaintiff should have a private right of action for violations of either the FFCRA or CARES Act through ERISA (or otherwise), this court should decline to infer such a right."
The lab's unjust enrichment and quantum meruit claims also fall short since the complaint is "devoid of any allegations plausibly suggesting that Cigna received some benefit from plaintiff," according to the insurer.
Counsel for the parties did not immediately respond to requests for comment Thursday.
The lab is represented by Peter Nichols of Levine Desantis LLC.
Cigna is represented by E. Evans Wohlforth Jr. and Charlotte Howells of Gibbons PC.
The case is Open MRI and Imaging of RP Vestibular Diagnostics PA v. Cigna Health and Life Insurance Co., case number 2:20-cv-10345, in the U.S. District Court for the District of New Jersey.
--Editing by Daniel King.
For a reprint of this article, please contact reprints@law360.com.
