1. Case Name: Annette Weil v. Cigna Health and Life Insurance Company, et al.
2. Type of Treatment Services Denied: Transcranial Magnetic Stimulation (“TMS”) for treatment of depression
Plaintiff: Meiram Bendat, Psych-Appeal, Inc., D. Brian Hufford, Jason S. Cowart, and Andrew Caridas, Zuckerman Spaeder, LLP
Defendants: Melvin N.A. Avanzado, Elaine W. Yu, The Avanzado Law Firm; Molly Moriarty Lane, Jeremy P. Blumenfeld, and Michael C. Higgins Morgan, Lewis & Bockius, LLP
4. Format: Stipulation of Settlement
- ERISA Claim: Yes
- Class Action/or Individual Action: Class Action
- Defendant: Health Plan Administrator
- Type of Insurance Plan: Group health benefit plan sponsored by the private-sector employer
- Type of Coverage Denial: Medically Necessary
6. Legal Pointer: This case settled.
7. Legal Issues and Causes of Action: Plaintiff filed suit for the denial of TMS for the treatment of depression.
Ruling: This case settled.
8. Narrative Case Description: Plaintiff suffers from Major Depressive Disorder, which has not been alleviated by psychotherapy, numerous administrations of anti-depressant medications, and Electro-Convulsive Therapy (“ECT”). In October 2014, Plaintiff’s treating mental health care providers recommended that Plaintiff undergo therapeutic repetitive Transcranial Magnetic Stimulation (“TMS” or “rTMS”) therapy. Cigna, however, denied Plaintiff’s request for pre-authorization for TMS therapy based on a medical policy that it created (“TMS Policy”), which analyzes TMS therapy and concludes that it is not covered by Cigna Plans because those plans all contain an exclusion for “experimental/investigational/unproven” services (the “E/I Exclusion”). Thereafter, Plaintiff proceeded to obtain TMS therapy, with tremendous results, and submitted TMS-related claims to Cigna.
Upon receipt of Plaintiff’s TMS claims, Cigna continued to deny tens of thousands of dollars in benefits. Following Cigna’s preauthorization and claims denials, Plaintiff exhausted all internal appeals provided by the Plan. Cigna responded to each level of appeal by upholding the denial of coverage based solely on its TMS Policy and the E/I Exclusion, and without considering the substantial materials submitted by Plaintiff and her providers supporting coverage for TMS. Thereafter, Plaintiff filed an external appeal with MCMC, a so-called “Independent Review Organization” (“IRO”), which upheld the denial on the same basis.
In denying coverage, Cigna followed its uniform TMS Policy, that mandates denial of coverage for TMS therapy for all Cigna-administered plans. In turn, MCMC rubber-stamped Cigna’s denial based on a perfunctory review by an anonymous child psychiatrist who lacked direct experience with TMS and who referenced outdated literature while ignoring a body of contemporary, peer reviewed, published evidence for TMS as a safe and effective treatment for Major Depressive Disorder. Plaintiff argues that neither Cigna nor MCMC properly applied the E/I Exclusion found in the Weil Plan.
9. Additional Comments: This case settled for $2.75 million. Plaintiff’s Motion for Attorneys’ Fees and Expenses and an Incentive Aware was also granted and the Court awarded fees in the amount of $907,500 and payment of expenses in the amount of $9,370.47. An incentive aware in the amount of $10,000 was also approved.
The settlement had three components: Cigna’s revision of its TMS policy; payment by Cigna of $2.75 million to the settlement class; and a release of certain claims against Cigna related to TMS. Cigna’s revised TMS policy allowed the use of FDA-approved TMS devices to treat depression.
11. Practical Implications and Lessons Learned: There is overwhelming evidence that TMS is safe and effective and is a generally accepted standard of medical practice for the treatment of depression within the mental health community. TMS therapy is a proven, efficacious treatment for depression, and is not experimental or investigational by any fair definition of those terms, and certainly not within the meaning of those terms as defined in the Weil Plan or in similar Cigna-administered plans. Cigna’s TMS Policy, and Defendants’ resulting denial of TMS coverage for Plaintiff violated the terms of the relevant plans and Defendants’ fiduciary obligations under ERISA.
12. All Legal Theories Presented in Case: Violation of ERISA, breach of fiduciary duty,
13. Successful Legal Theories in Case: This case settled.