There is no Statutory Right to Defraud an Insurer скачать в хорошем качестве

There is no Statutory Right to Defraud an Insurer

Counterclaim Seeking Payment of its Fraudulent Bills Fails Post number 5297 Fraudsters Attempt to Use Statute to Force Payment Fails  In Connecticut General Life Insurance Co. et al. v. East Coast Advanced Plastic Surgery, LLC, No. 25 Civ. 1686 (PAE), United States District Court, S.D. New York (February 24, 2026) a dispute between Connecticut General Life Insurance Company and its subsidiary Cigna Health and Life Insurance Company (collectively, "Cigna") and East Coast Advanced Plastic Surgery, LLC ("ECAPS"), a New Jersey-based medical practice specializing in post-mastectomy breast reconstruction. Cigna alleged that ECAPS engaged in fraudulent billing practices, resulting in excessive payments for services rendered to patients covered under Cigna-insured and self-funded employer health plans ("SFPs"). ECAPS counterclaimed, asserting that Cigna and the SFPs failed to pay for services provided and unlawfully demanded that ECAPS engage in balance billing, a practice prohibited by the No Surprises Act ("NSA"). FACTUAL BACKGROUND Since January 1, 2022, ECAPS has provided its specialized breast reconstruction services to hundreds of Cigna patients. Consistent with the MPI Agreement, ECAPS and its doctors have routinely submitted their claims for payment for such services to Cigna.  ECAPS alleged that Cigna, acting on behalf of the SFPs, violated the terms of that agreement-and of the NSA. LEGAL ISSUE The central legal issue involves the application of the No Surprises Act, 29 U.S.C. § 1185e, which bars certain billing practices, including balance billing, and sets forth requirements for insurer payments to out-of-network providers. ECAPS brought a counterclaim under the NSA against Cigna, over 25 named SFPs, and "John Doe Cigna Self-Funded Plans 1-2000," alleging violations of the NSA’s statutory payment and billing prohibitions. DISCUSSION The court reviewed the sufficiency of ECAPS' NSA counterclaim in light of motions to dismiss filed by Cigna and two SFP defendants. ECAPS sought a declaration of NSA violations, a permanent injunction against further violations, and reimbursement for unpaid services. The court previously sustained most of Cigna’s fraud claims but had already dismissed ECAPS' original claims under Rule 12(b)(6), reflecting skepticism about the counterclaims’ legal sufficiency. ANALYSIS In its analysis, the court found that ECAPS’ counterclaim did not sufficiently allege actionable violations of the NSA by Cigna or the SFPs. The court concluded that the facts as pled did not support a plausible claim that the defendants failed to comply with the NSA’s payment mandate or engaged in prohibited balance billing practices. Accordingly, the court granted the motions to dismiss the counterclaim. THE COUNTERCLAIM The counterclaim alleges two violations of the NSA. the counterclaim alleged that the counterclaim defendants violated the NSA's prohibition on balance billing, which provides that a group health plan “shall not impose on such participant or beneficiary a cost-sharing requirement for such items and services so furnished that is greater than the cost-sharing requirement that would apply under such plan . . . had such items or services been furnished by a participating provider.” 29 U.S.C. § 1185e(b)(1)(A). In other words, where Cigna patients receive treatments at participating healthcare facilities by out-of-network providers such as ECAPS, those patients cannot be made to pay more for such services than if they had received them from in-network providers. WHETHER THE NSA PERMITS CLAIMS FOR EQUITABLE RELIEF Cigna argued correctly that the counterclaim should be dismissed because, as the Court held in the MTD Decision, the NSA does not give rise to a private right of action. The counterclaim fails at the first step. Since there is no right of action under the NSA, the Court has no occasion to consider the nature of the relief sought or whether it is proper under that statute. Lacking a statutory right of action, ECAPS's bid for equitable relief fails. Accordingly, the Court dismisses the counterclaim. ZALMA OPINION No one has, nor should anyone have, a right to commit fraud against an insurer. ECAPS sought equitable relief and its higher and fraudulent billing should be paid under a federal statute. The USDC found the NSA does not allow a private right of action and its counterclaim fails and must be dismissed. (c) 2026 Barry Zalma & ClaimSchool, Inc. Please tell your friends and colleagues about this blog and the videos and let them subscribe to the blog and the videos. Subscribe to my substack at https://barryzalma.substack.com/subsc... Go to X @bzalma;  Go to Barry Zalma videos at Rumble.com at https://rumble.com/account/content?ty... Go to Barry Zalma on YouTube- https://www.youtube.com/channel/UCysi... Go to the InsuranceClaims Library – https://lnkd.in/gwEYk.