L.P. v. CRUNCHY DATA SOLUTIONS, INC.

CourtDistrict Court, D. New Jersey
DecidedJuly 11, 2023
Docket3:22-cv-02004
StatusUnknown

This text of L.P. v. CRUNCHY DATA SOLUTIONS, INC. (L.P. v. CRUNCHY DATA SOLUTIONS, INC.) is published on Counsel Stack Legal Research, covering District Court, D. New Jersey primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
L.P. v. CRUNCHY DATA SOLUTIONS, INC., (D.N.J. 2023).

Opinion

UNITED STATES DISTRICT COURT DISTRICT OF NEW JERSEY

L.P., Civil Action No. 22-2004 (RK)

Plaintiff,

v. MEMORANDUM OPINION

CRUNCHY DATA SOLUTIONS, INC., et al.,

Defendants.

BONGIOVANNI, Magistrate Judge This matter is brought before the Court upon motion by Plaintiff, L.P. (“Plaintiff”), seeking an Order compelling discovery from Defendant, Cigna Health and Life Insurance Company (“Defendant” or “Cigna”), to provide responses to its discovery requests. Defendant opposes Plaintiff’s motion to compel discovery. The Court has fully reviewed all arguments raised in support of and in opposition to Plaintiff’s motion. For the reasons that follow, Plaintiff’s motion to compel discovery is DENIED. I. BACKGROUND AND PROCEDURAL HISTORY Plaintiff filed his Complaint in the District Court of New Jersey on April 7, 2022, seeking recompense from Cigna for medical benefits due under Crunchy Data Solutions, Inc.’s Open Access Plus Employee Welfare Benefit Plan (the “Plan”) as governed by the Employee Retirement Insurance Security Act of 1974 (“ERISA”). In accordance with Section 502(a) of ERISA, 29 U.S.C. § 1132(a)(1)(B), Plaintiff sought recovery “by way of an injunction requiring defendants to pay usual, customary, and reasonable charges for a surgical procedure that has been deemed to be medically necessary.” (Compl. ¶ 1, Docket Entry No. 1). On October 17, 2022, the parties served each other with Interrogatories and Requests for the Production of Documents. In response, both parties objected to all requests and declined to provide any discovery beyond the administrative record. Pursuant to the Court’s request, the parties submitted a Joint Discovery Plan on September 23, 2022. After an attempt to meet and confer on December 19, 2022, the parties

informed the Court of the underlying dispute concerning discovery beyond the administrative record, and, on January 9, 2023, the Court granted leave for Plaintiff to file the instant motion to compel. A. BACKGROUND Plaintiff’s claims arise from the medical benefits and services owed to him by Crunchy Data, the “Plan Administrator.” (Compl. ¶ 12-15, Docket Entry No.1, Ex. 1). Cigna—whom Crunchy Data designated as the benefits and claims administrator of the Plan—has “[t]he discretionary authority to interpret and apply Plan terms and to make factual determinations in connection with its review of claims under the Plan.” (Id. ¶ 12-15). The Plan provides medical benefits for both in network and out-of-network services; however, out-of-network services are

not covered without authorization from Cigna. (Id. ¶ 18). For the out-of-network services that Cigna approves, payment is based upon a “Maximum Reimbursable Charge” which the Plan defines as the lesser of: ● [T]he provider’s normal charge for a similar service or supply; or ● An Employer-selected percentage of a fee schedule developed by Cigna that is based upon a methodology similar to a methodology utilized by Medicare to determine the allowable fee for the same or similar service within the geographic market.

The percentage used to determine the Maximum Reimbursable Charge is the 110th percentile.

In some cases, a Medicare based schedule will not be used and the Maximum Reimbursable Charge for covered services is determined based on the lesser of: ● The provider’s normal charge for a similar service or supply; or ● The 80th percentile of charges made by providers of such service or supply in the geographic area where it is received as compiled in a database selected by Cigna. If sufficient charge data is unavailable in the database for that geographic area to determine the Maximum Reimbursable Charge, then data in the database for similar services may be used.

The Maximum Reimbursable Charge is subject to all other benefit limitations and applicable coding and payment methodologies determined by Cigna.

(Id. ¶ 18-20). Plaintiff sought authorization from Cigna to have Dr. Kauffman of The Plastic Surgery Center, P.A. (“TPSC”)—an out-of-network provider not subject to the terms of the Plan—perform phrenic nerve reconstructive surgery (the “Surgery”). (Id. ¶ 36-40). Cigna, after initially denying Plaintiff's request for authorization, revoked its original decision and authorized the Surgery on the grounds that it was “medically necessary” but required that payment be based on an “in- network” rate rather than that of the out-of-network rate, i.e. the Maximum Reimbursable Charge. (Id. ¶ 36-37). Dr Kaufman and TPSC submitted to Cigna the “usual, customary, and reasonable (“UCR”) charges for the Surgery” to which Cigna did not respond. (Id. ¶ 38). Plaintiff alleges that Cigna’s approval of the Surgery, but refusal to negotiate, was tantamount to a denial of medically necessary treatment covered by the Plan. (Id. ¶ 63). On March 3, 2022, TPSC, on behalf of Plaintiff, filed a Level One Pre-Service Appeal (“Appeal”), requesting that Cigna either authorize payment or provide an alternative surgeon to perform the Surgery. (Id. ¶ 45). Cigna did not respond to Plaintiff or TPSC regarding the Appeal. Plaintiff asserts that Cigna’s failure to respond is indicative of its non-compliance with the internal appeal process and is thereby tantamount to a denial to provide medical services as covered by the Plan. (Id. ¶ 48-50). B. DISCOVERY DISPUTES On September 23, 2022, the parties submitted to the Court a Joint Discovery Plan wherein Plaintiff stated it would: be seeking discovery concerning the procedural irregularities in Defendants’ [sic] claims handling process, conflicts of interest between Cigna and Plaintiff’s employer [Crunchy Data Solutions, Inc. [(“Crunchy Data”)], the methodologies employed by Defendant [Cigna] and their representatives in making claims determinations, negotiation and payment protocol concerning out-of-network providers, etc.

(Certification of Charles R. Mathis IV in Support of Plaintiff’s Motion to Compel (“Certif”) ¶ 6 at 2). Plaintiff further asserted Cigna was not entitled to discovery beyond the administrative record because Cigna “has discretionary authority to interpret terms of the Plan and render benefit determinations” and was thereby reviewed under the “arbitrary and capricious” standard. (Brief of Plaintiff, L.P., In Support of His Motion to Compel Defendant, Cigna To Answer Discovery (“Pl. Brief”)). On October 17, 2022, both Plaintiff and Cigna served one another with Interrogatories and a Request for the Production of Documents. (Pl. Brief at 7, Ex. 4, 5). Both parties rebuffed the discovery requests of the other. On December 8, 2022, Plaintiff forwarded further correspondence to Cigna requesting responses to the discovery requests within ten (10) days to remediate the discovery deficiencies. (Pl. Brief at 7, Ex. 8). In response, Cigna contacted Plaintiff to request a telephone conference to discuss the outstanding discovery. (Pl. Brief at 7, Ex. 8). On December 19, 2022, Plaintiff and Cigna conferred, with Cigna requesting that Plaintiff narrow their discovery responses. (Pl. Brief at 8). The parties notified the Court that the issue was not resolved and on January 9, 2023, Plaintiff was granted leave to file this motion to determine whether Plaintiff is entitled to discovery beyond the administrative record. (Pl. Brief at 8). II. THE PARTIES’ ARGUMENTS A. PLAINTIFF’S ARGUMENTS In its opening brief on this motion, Plaintiff argues that it is entitled to discovery beyond the administrative record because of procedural irregularities; Plaintiff claims that the discovery it

seeks is necessary for the preparation of trial and in evaluating “whether the denial by Cigna of the Surgery [was] arbitrary and capricious.” (Pl. Brief at 9).

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