C&T Litigating Class Action Lawsuit Related To Utilization Management Review Of Out-Of-Network Chiropractic Providers’ Treatment By Cigna And American Specialty Health Networks

C&T Litigating Class Action Lawsuit Related To Utilization Management Review Of Out-Of-Network Chiropractic Providers’ Treatment By Cigna And American Specialty Health Networks

C&T and its co-counsel are litigating a class action lawsuit against Cigna and American Specialty Health Networks (“ASH”) on behalf of chiropractors who have treated Cigna insureds on an out-of-network basis, alleging that Cigna and ASH impose utilization management review (UMR) requirements on out-of-network chiropractic providers in a deliberate effort to avoid paying benefits in violation of ERISA and the terms of Cigna insurance plans.

According to the amended complaint, while the standard Cigna insurance plan excludes from coverage services which are not medically necessary, it does not require routine submission of clinical records to substantiate medical necessity on a pre-service, concurrent or post-service basis. In essence, ASH’s utilization review requirements are not disclosed or explained or required in the plan documents.  Instead of following the definition of “medical necessity” incorporated into the CIGNA Plans, ASH imposes its own, more restrictive, coverage guidelines that are designed to justify numerical limitations on covered services. As a result, ASH’s utilization review process results in arbitrary and capricious denials of coverage and restrictions on care.

This lawsuit is pending in the Eastern District of Pennsylvania at High Street Rehab., LLC, et al. v. American Specialty Health Inc., et al., No. 12-7243 (E.D. Pa.). A copy of the amended complaint can be viewed below.