United States District Court, S.D. New York
February 18, 2014
MANHATTAN TOTAL HEALTH & GENERAL MEDICINE, P.C., MANHATTAN TOTAL HEALTH & MEDICAL FITNESS, P.C., and MANHATTAN TOTAL HEALTH & PHYSICAL MEDICINE, P.C., Plaintiffs,
CIGNA CORPORATION, CIGNA HEALTHCARE OF NEW YORK, INC., CONNECTICUT GENERAL LIFE INSURANCE COMPANY, ORTHONET NEW YORK IPA, INC., and ORTHONET LLC., Defendants.
John A. Darienzo Jr., Esq., Frank Wieziolowski, Esq., HALPERN, BROWN & DARIENZO, ESQS., Brooklyn, New York, Attorneys for Plaintiffs.
E. Evans Wohlforth, Jr., Esq., Daniel S. Weinberger, Esq., GIBBONS P.C. Newark, New Jersey, Attorneys for Defendants CIGNA Corporation, CIGNA Healthcare of New York, Inc., and Connecticut General Life Insurance Company.
Kevin M. Ryan, Esq., JONES HIRSCH CONNORS MILLER & BULL P.C., New York, New York, Attorneys for Defendants Orthonet New York IPA, Inc, and Orthonet LLC.
MIRIAM GOLDMAN CEDARBAUM, District Judge.
This is a suit for monetary and injunctive relief under Sections 502(a)(1)(B) and 502(a)(3) of the Employee Retirement Income Security Act (ERISA), 29 U.S.C. § 1132(a)(1)(B), (a)(3). Healthcare provider Manhattan Total Health & General Medicine, P.C and affiliated companies (collectively, "MTH") sue on behalf of approximately 134 of their patients. They allege that insurance plan administrator CIGNA Corporation and affiliates (collectively, "CIGNA") and utilization-review contractor Orthonet LLC and affiliate (collectively, "Orthonet") breached various duties by failing, when making benefit-eligibility determinations, to place decisionmaking authority with physicians specializing in the field of treatment under consideration. Both groups of defendants now move to dismiss MTH's third amended complaint for failure to state a claim.
After four attempts, MTH still has not alleged a duty on Orthonet's part to use same-specialty physicians when conducting its initial review of patients' claims. The governing insurance plans contain no language to that effect, and MTH has identified no statutory or fiduciary duty supporting a claim under the statute's "catchall" provision, § 502(a)(3).
The latest complaint does, however, properly allege a plan violation by CIGNA, the entity responsible for hearing appeals of denied claims. One of the plans provides that first-level appeals "will be considered by a health care professional of the same or similar specialty as the care under consideration." 3d Am. Compl. Ex. C. The other plan states that the second-level appeals committee "will include at least one Physician reviewer in the same or similar specialty as the care under consideration." Id . Ex. D. Taking as true MTH's allegation that CIGNA failed to use same-specialty physicians at any point in the appeals process, the complaint states a claim for violation of the plans.
Whether MTH's § 502(a)(1)(B) claim against CIGNA is duplicative of its § 502(a)(3) claim, see Varity Corp. v. Howe , 516 U.S. 489, 515 (1996), need not be resolved at this stage of the proceedings; suffice it to say that any theory of recovery must be grounded in the concrete terms of the governing plans. Like Orthonet, CIGNA has no extra-contractual duty to review claims using same-specialty physicians.
Accordingly, Orthonet's motion is granted and CIGNA's motion is denied. MTH's claims against Orthonet New York IPA, Inc. and Orthonet LLC are dismissed.