Knowing your rights and the requirements necessary in pursuing a claim if you have been denied benefits under an employee benefit plan are crucial. A recent case involving multiple Cigna entities, Connecticut General Life Insurance Company, and the NFL Player Insurance Plan shows how important this really is and why it matters to you.
The insurance companies and the NFL Player Insurance Plan are collectively seeking a little more than $1,000,000 in attorney fees following a lawsuit involving health benefit claims. The lawsuit, Advanced Physicians, S.C. v. Conn. Gen. Life Ins. Co. (case number 3:16-CV-2355-G), was filed in 2016 and is currently before the United States District Court for the Northern District of Texas. The Plaintiff in this case was Advanced Physicians, S.C., a medical facility that began treating retired NFL players in 2007. The NFL Player Insurance Plan provides medical benefits to both current and former NFL players. The insurance plan is governed by a federal law called the Employee Retirement Income Security Act of 1974. This Act is often shortened to “ERISA.”
After a lengthy 5-year litigation, the Court granted judgment in favor of the Defendants, who included both Cigna and the NFL Player Insurance Plan. The NFL plan designated insurance companies to be the administrator of the plan. Connecticut General Life Insurance Company and Cigna were both named administrators at various times under the plan. At the time of the lawsuit, Cigna processed claims submitted under the NFL plan and made determinations on whether to approve or deny health claims. Leading up to the lawsuit, Advanced Physicians, S.C. had submitted claims through the NFL plan on behalf of its patients. The lawsuit was filed by Advanced Physicians, S.C. after certain denials of health benefits occurred under the NFL plan.
There are certain requirements that typically must be met if a benefit plan is governed by ERISA. One of these requirements is that individuals must typically exhaust any required administrative appeals with the insurer or administrator prior to filing a lawsuit regarding a denial of benefits. In the Cigna/NFL case, it was argued that Advanced Physicians, S.C. failed to satisfy the appeal requirements set forth in the NFL plan. The Court agreed and, in part, ruled in favor of Cigna and the NFL plan because of Advanced Physicians, S.C.’s failure to exhaust the appeal requirements. Because the Court decided against the Plaintiff in this case, the insurance companies and the NFL plan are now seeking over $1,000,000 collectively in attorney fees against the Plaintiff. The insurance companies and the NFL plan have both filed individual motions with the Court requesting their attorney fees be paid. The Court has not yet made a decision on these requests.
Mehr, Fairbanks & Peterson regularly handles ERISA cases. It is important to reach out to attorneys that can help you navigate this process and protect your rights to benefits. Mehr, Fairbanks & Peterson may be able to help you. Call us today for a free consultation.
This information should not be construed as legal advice or a guideline to your specific claim.