Case: 1:22-cv-01575 Document #: 1 Filed: 03/25/22 Page 1 of 8 PageID #:1

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF ILLINOIS
EASTERN DIVISION

ADVANCED PHYSICAL MEDICINE )

OF YORKVILLE, LTD., an Illinois medical )
corporation, )
Plaintiff, )
) Case No.:
vs. )
)
CIGNA HEALTHCARE OF ILLINOIS, INC., AN )
Illinois corporation, and CIGNA HEALTH )
MANAGEMENT, INC., a Delaware )
Corporation, )
Defendant. )

COMPLAINT

NOW COMES the Plaintiff, ADVANCED PHYSICAL MEDICINE OF YORKVILLE,

LTD., by and through its attorneys, LAW OFFICES OF MCLAUGHLIN & ASSOCIATES, P.C.,

and for its Complaint against CIGNA HEALTHCARE OF ILLINOIS, INC., an Illinois

corporation, and CIGNA HEALTH MANAGEMENT,INC., a Connecticut Corporation, states as

follows:

Nature of the Action

1. This action is brought under provisions of the Employee Retirement Income

Security Act (ERISA) to recover benefits due under the terms of a health benefits plan under 29

U.S.C. g 1132(aX1)(B) and for statutory penalties pursuant to 29 U.S.C. $ 1132(a)(l)(A), as

defined in 29 U.S.C. $ 1132(cX1), modifiedby 29 C.F.R. $ 2575.502c-1.

2. Plaintiff treated patient Deborah Priebe ("Patient") with chiropractic manipulative

treatments and therapeutic exercises, defined fuither below ("the Services") between the dates of

June25,2020,and March 27,202L The Services are covered under Patient's health benefits plan,
 Case: 1:22-cv-01575 Document #: 1 Filed: 03/25/22 Page 2 of 8 PageID #:2

CIGNA East, Plan No. xxxx224 ("the Plan"). The Plan is a group health benefits plan subject to

ERISA.

3. Plaintiff is the assignee of benefits for health care services Plaintiff provided to

Patient and Patient's designated authorized representative. Patient has conveyed to Plaintiff all

rights to pursue recovery of benefits due under the Plan for the Services and to bring derivative

actions on his behalf to recover such benefits and to pursue any other available remedies under the

law. This assignment was in effect during all times relevant to this Complaint. A true and correct

ofthe Patient Consent and Legal Assignment of Benefits dated June25,2020 is attached as Exhibit

" A.t'

4. Count I of this action is brought to recover health benefits due to Plaintiff under the

Plan for claims that Defendarrtarbrtrarily and capriciously denied. Count II of this action is brought

to collect statutory penalties against Defendant for Defendant's failure to provide Plaintiff with

certain Plan documents requested by Plaintiff.

Parties

5. Plaintiff, Advanced Physical Medicine of Yorkville, Ltd. is an Illinois medical

corporation with its principal place of business located at207 Hillcrest Avenue, Suite A, Yorkville,

Kendall County, Illinois 60560. Plaintiff provided chiropractic and other medical treatment to

Patient under the Plan as set forth herein.

6. Defendant, CIGNA HealthCare of Illinois, Inc., ("CHC"), the Plan Provider for

the Plan, is an Illinois corporation with its principal place of business located at 525 W.

Monroe St., Chicago, IL 60661, and its registered agent located at208 S. LaSalle St., Suite

814, Chicago,IL 60604. Upon information and belief, CHC retained fiduciary responsibilities

under the Plan to pay claims under the Plan, including those of Patient's.

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7. Defendant CIGNA Health Management, Inc', ("CHM"), the Plan

Administrator for the Plan, is a Delaware corporation, licensed to transact business in the State

of Illinois, with its principal place of business located at 1601 Chestnut St., Philadelphia, PA

lglg2, and its Illinois registered agent located at208 S. LaSalle St., Suite 814, Chicago, IL

60604. Upon information and belief, CHM had fiduciary responsibilities under the Plan to

administrator and make proper determinations under the Plan for payment of claims, including

those of Patient's.

8. Patient resides in Yorkville, Kendall County, Illinois.

Jurisdiction and Venue

g. This Court has subject matter jurisdiction under 28 U.S.C. $ 1331 for all claims

asserted in this Complaint. A11 claims in this complaint pose questions of federal law arising under

provisions of ERISA. Additionally,2g U.S.C. $ 1 132(e)(1) grants the U.S. district courts exclusive

jurisdiction of claims brought under 29 U.S.C. $ 1132(aX1)(A) and concunent jurisdiction for

claims brought under 29 U.S.C. $ 1132(a)(1)(B).

10. This Court has personal jurisdiction over Defendants because as Plan Administrator

and Plan Provider, Defendants administered and were responsible for providing benefits under

Patient's Plan in the Northern District of Illinois and denied claims under the Plan's coverage for

services rendered in the Northern District of Illinois.

I 1. Venue is proper in the Northern District of Illinois under 28 U.S.C. $ 1391(b)(2) as

a substantialpart of the events giving rise to these claims occurred in this district and under 29

U.S.C. g 1132(e)(2) as the district in which the health benefits plan was administered.

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Common Facts

12. Plaintiff submitted approval to CHM for the Services for Patient, which included

27 office visits/chiropractic manipulative adjustments and 27 therapeutic exercise services,

between |une25,2020, and March 27,202L The Services were covered under the Plan. As

Patient's authorized representative, Plaintiff submitted claims to CHM on Patient's behalf for the

Services.

13. On or about October 6,2020, CHM agreed to pay for 18 office visits/chiropractic

manipulative adjustments and 18 therapeutic exercise services but denied the remaining 9 office

visits/chiropractic manipulative adjustments and 9 therapeutic exercise services on two (2)

grounds: (a) "Your [the Patient's] condition is chronic....We need to know your response to care

before more treatment can be considered." (b) Your [the Patient's] condition was not caused by

trauma. . ..This type of condition should respond well and need less care." A true and correct copy

of the denial is summarized on Exhibit "B." CHC did not pay the denied Services following

CHM's denial of Services.

14. On October 8,2020, as Patient's authorized representative, Plaintiff submitted its

first appeal of the denied Services for service dates June 29 , 2020 through October 8, 2020 on the

the specific
grounds that "it fthe denial] fails to provide the specific reason or reasons for denial and

reference to pertinent plan provisions on which the denial is based." Plaintiff s appeal included a

request for Patient's SPD, a reviewing physician's report, and all pertinent information related to

the denial of Services. A true and correct copy of the October 8,2020 appeal is attached as Exhibit

"c."
15. On November 18, 2020, CHM responded to Plaintiffs first appeal and denied

coverage for the Services under CPT codes 99214 and 98940 on the grounds that the Services were

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not medically necessary because "the fPatient's medical] records do not include objective

measurements of improvement." A true and correct copy of said denial is attached as Exhibit "D."

CHC did not pay the denied Services following CHM's denial of Services.

16. Plaintiff provided CHM with Patient's medical records that showed objective

measurements of 22.5-26.7% improvement, which CHM had for review prior to its November 18,

2020 denial.

17 . On December 1, 2020, as Patient's authorized representative, Plaintiff submitted a

second appeal of the claim denials for the Services to CHM, updated to include service dates

through November 12,2020. This appeal directed CHM's attention to medical records from

August 3,2020-August 3I,2020 of 22.5% improvement and from August3l,2}2}-November 3,

2020 of 26.7% improvement. A true and correct copy of the December l't appeal is attached as

Exhibit "E."

18. On January 6, 202I, CHM denied the second appea| again claiming that the

treatment was not medically necessary because "the records do not include successive objective

measurements for improvement." A true and correct copy of said denial is attached as Exhibit

"F." CHC did not pay the denied Services following CHM's denial of Services.

D . On May 20, 2021 , as Patient's authorized representative, Plaintiff submitted a third

appeal of the claim denials for the Seruices to CHM, with an outstanding balance for Services

provided under the Plan of $18,975.77. This appeal included all previously provided medical

records and appeals, as referenced in "Enclosures, 2. Previously submitted requests and appeals."

A true and correct copy of the May 20th appeal is attached as Exhibit "G."

20. To date, CHM has not responded to the third appeal. CHC has continued to fail to

pay the denied Services.

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21. To date, Plaintiff s the claims for Services of $18,975.77 rcmainunpaid.

Count I: Recoverv of Benefits Due Under Plan Pursuant to 29 U.S.C. Q 1132(aX1XB)

l-21. Plaintiff realleges paragraphs l-21 as though fully set forth herein.

22. Plaintiff brings Count I under 29 U.S.C. $ 1132(a)(1)(B) to recover benefits due

Plaintiff under Patient's Plan that CHM arbitrarily and capriciously denied.

23. Plaintiff has exhausted its administrative remedies regarding the disputed denials

of benefits for the Services under 29 C.F.R. $ 2560.503-t(lx1). CHM failed to follow procedures

consistent with a full and fair review of Plaintiff s appeal as required by 29 U.S.C. $ 1 133(2) and

defined under 29 C.F.R. $ 2560.503-1.

24. CHM failed to provide the specific reason or reasons for denial and the specific

reference to pertinent plan provisions on which the denial was based, or to the extent CHM

provided a reason, it was not rationally based on a review of the medical records provided to it.

25. CHM did not provide Plaintiff with the reviewing physician's report or any

communication relevant to the Patient's adverse benefit determination upon written request as

required by 29 U.S.C. 1024(b)(4) and29 CFR 2560.503-1(ixs).

26. CHC is liable as a fiduciary under the Plan for CHM's denials and for failure to pay

the claims for the denied Services.

27 . Therefore, Plaintiff is entitled to recover the full amount of its claim for $18,975.77

from Defendants.

28. Plaintiff is entitled to recover its reasonable attorney's fees under 29 U.S.C. $

I 1 32(gX1 ) from Defendants.

WHEREFORE, for the foregoing reasons, Plaintiff ADVANCED PHYSICAL

MEDICINE OF YORKVILLE, LTD., respectfully requests this Court to enter judgment in its

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Case: 1:22-cv-01575 Document #: 1 Filed: 03/25/22 Page 7 of 8 PageID #:7

favor and against Defendants, CIGNA HEALTHCARE OF ILLINOIS, INC. and CIGNA

HEATHCARE MANAGEMENT, INC., in the amount of $18,975.77 plus attorney's fees and

costs and such other relief as this Court deems just.

Count II: Recoverv of Statu torv Penalties Pursuant to 29 U E I132(a)(l)(A)

l-28. Plaintiff realleges paragraphs 1-28 as though fully set forth herein.

29. 29 CFR 52520.104b-1(a) and29 U.S.C. 1024(bX1) require aplan administratorto

furnish a copy of Plan documents, including but not limited to the summary plan document

("SPD"), to a participant or beneficiary within ninety (90) days of a written request.

30. 29 U.S.C. g 1132(c)(1)(A), as modified by 29 C.F.R. 5 2575.502c-1, provides for

a penalty of up to $110.00 per day to be applied to any plan administrator who "fails or refuses to

comply with a request for any information which such administrator is required by this subchapter

to furnish to a participant or beneficiary [. . .] within 30 days."

31. Plaintiff is a participant or beneficiary under the Plan administered by Defendant

under the assignment of benefits attached as Exhibit "A." Plaintiff may therefore bring suit against

Defendant under 29 U.S.C. $ 1132(aX1)(A) to recover the above referenced statutory penalties.

32. CHM is responsible for administering the Plan in compliance with the requirements

of 29 U.S.C. $ 1024(b)(2) under the Plan.

33. Plaintiff requested the documentation on which CHM based its denial. CHM

delayed providing the SPD by 8 months. Apart from the SPD, CHM has yet to provide the

requested documents.

34. Therefore, Plaintiff is entitled to recover a statutory penalty against CHM of $1 10

per day for its delay in providing requested Plan documents.

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WHEREFORE, for the foregoing reasons, Plaintiff ADVANCED PHYSICAL

MEDICINE OF YORKVILLE, LTD., respectfully requests this Court to enter judgment in its

favor and against Defendant, CIGNA HEALTHCARE MANAGEMENT, INC., as follows:

A. Award Plaintiff recovery of statutory penalties of $110 per day pursuant to 29

U.S.C. g 1132(c)(1)(A), as modified by 29 C.F.R. 52575.502c-1, from August 8,2020 to date for

CHM's failure to provide requested Plan documents, which continue to accrue daily; and

B. Award Plaintiff the cost of reasonable attorney's fees as allowed under 29 U.S.C.

$ 1132(gX1).

Respectfully submitted,

Law OrncES oF McLAUGHLIN & AssocrerEs, P.C.

By:
One of the P s Attorneys

Kenneth S. Mclaughlin, Jr.

ARDC No. 6229828
Lew Orn'rcES oF McLAUGHLIN & AssocnrEs, P.C.
1 E. Benton Street, Suite 301
Aurora,IL 60505
630-230-8434
630-230-8435 fax
kmcl aughl in@ma-lawpc. co m