One tool that can be effective in correcting unfairness with underpaid medical benefit claims is the class-action. An example can be seen in the recent class action filed in the United States District Court for the District of Connecticut, Stewart et al v. Cigna Corporation and Cigna Health and Life Insurance Company (case 3:22 – CV – 00769).
This case alleges that the Cigna companies breached fiduciary duties of loyalty and honoring plan terms by paying participating medical providers at a lower nonparticipating provider rate. This resulted in underpaying millions of dollars to medical providers, which are then passed on to patients.
The American Medical Association has now joined the lawsuit. It stated,
“By joining Stewart v. Cigna as a plaintiff, the AMA hopes to shed light on Cigna's misconduct, and create remedies so that patients and physicians can look forward to getting what they are promised.”
It is encouraging to see patients and physicians banding together to fight this unfairness.
The allegations also reflect violations of the No Surprises Act (NSA), which according to the US departments of Health and Human Services, Labor, and Treasury, is supposed to
“restrict surprise billing for patients in job-based and individual health plans who get emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.”
This act was passed in 2021. Regulations were published with an effective date of September 13, 2021. The NSA added section 9816 of the Code, section 716 of ERISA, and section 2799A-1 of the PHS Act (Public Health Services Act).
As an aside, but related to the NSA, in many personal injury claims, there may be serious and tragic circumstances requiring air ambulance transportation. Sometimes, health plans exclude coverage for such transportation, or there is no insurance. In those instances,
“Providers, facilities, and air ambulance providers are also required to give uninsured (or self-pay) individuals good-faith estimates of expected charges for scheduled health care services and may have to participate in a patient-provider payment dispute resolution process if their billed charges are higher than the good-faith estimates.”
Those charges are often reimbursed at a much lower rate than what is billed when covered. That fact, along with violations of this act, may provide leverage in negotiations to resolve such charges.
It will be interesting to see how this potential class action shapes up. Let me know your thoughts on class actions for medical benefit claims.