California Court orders CIGNA to disclose amount paid to MES Solutions for medical reviews

CIGNA Insurance Company can run but they can’t hide. Recently, the US District Court for the Central District of California granted Plaintiff Bradley Wojno’s Motion to Compel Defendant CIGNA Insurance to reveal the extent of it financial relationship with MES Solutions. Mr. Wojno’s disability attorney sought information from CIGNA that could unveil potential conflicts and biases of CIGNA’s hired gun doctors relied upon to terminate Mr. Wojno’s disability benefits.

CIGNA argues the information sought by Plaintiff is “wholly irrelevant.”

CIGNA terminated Plaintiff’s disability benefits based largely on testing performed by Dr. Schoenberg who was supplied to CIGNA by MES Solutions (“MES”), a company that supplies medical professionals to insurance companies for claim determinations. In order to determine the potential biases of MES and Dr. Schoenberg, plaintiff sought information on the amount of money paid by CIGNA or its affiliates to MES in the years 2006 through 2010 for medical examinations and medical reviews of claimants. CIGNA argued that the information sought is “wholly irrelevant,” but nonetheless agreed to provide the information pursuant to a protective order limiting access to the information to attorneys only.

Court rules that information sought is relevant to the parties’ claims and defenses.

The court explained that potential conflicts and biases of Dr. Schoenberg, on whom CIGNA relied to terminate the Plaintiff’s disability benefits, are plainly relevant. Furthermore, denying Plaintiff’s requested discovery would deny Plaintiff information that may bear on potential biases of MES and Dr. Schoenberg.

If CIGNA has relied on MES physicians over the years, this fact may indicate that MES, in order to obtain more business from CIGNA, supplies CIGNA with physicians likely to provide claim determinations favorable to CIGNA.

Traditionally, there has been little or no discovery permitted in ERISA cases, as benefit determinations are based on the administrative record.

In reviewing benefits determinations, courts have traditionally allowed little or no discovery in ERISA cases. This is because open-ended discovery would “frustrate a primary goal of ERISA to resolve benefit disputes inexpensively and expeditiously.” However, courts have permitted consideration of evidence outside the administrative record in de novo standard of review-benefit denials. In Welch v. Metropolitan Life Ins. Co. the 9th Circuit Court of Appeals recognized that discovery aimed at demonstrating a conflict of interest was appropriate.

CIGNA contends that Plaintiff’s discovery is legally irrelevant because discovery typically is done to achieve a shift in the standard of review from abuse of discretion to de novo.

In reviewing ERISA cases, courts typically apply a de novo standard of review or an abuse of discretion standard. When the abuse of discretion standard is used, a court defers to the administrator’s findings and merely decides whether reasonable grounds supported the administrator’s decision. In a de novo review however, a court affords no deference to the administrator’s decision and reviews the claim as if it were for the first time.

CIGNA argued that Plaintiff’s discovery was legally irrelevant because it was not intended to achieve a shift in the standard of review given that CIGNA had already agreed that de novo review was applicable. However, CIGNA’s argument did not consider the Plaintiff’s purpose to determine the potential biases of MES and Dr. Schoenberg based on the amount of money received by MES and the incentive MES may have had in supplying medical professionals likely to be favorable to CIGNA. Furthermore, the court noted that CIGNA failed to cite any case that bars all discovery in de novo cases or to address the potential biases of MES and Dr. Schoenberg.

CIGNA failed to adequately demonstrate why a protective order was necessary.

Because the information sought by the Plaintiff was considered by CIGNA to be “commercially sensitive,” CIGNA pleaded for a protective order to safeguard such information. However, CIGNA failed to convince the court that protective measures were necessary and the court granted Plaintiff’s motion. The court therefore granted Plaintiff’s Motion to Compel without benefit of protective order. We look forward to seeing this information as we believe that CIGNA has paid MES a significant amount of money over the past years.

Comments (4)

  • I requested an independent review at the beginning of October 2021. My deductible of $1500.00 had been met. And after exhausting all attempts to get somewhere with my health insurance provider after not finding anyone in their network of doctors to properly care for my needs; I couldn’t get my doctor approved through my health insurance provider for out of network benefits. Before requesting the independent review I had been denied three times by my health insurance. They deemed my surgery was “experimental/investigational”. I requested in writing like I was informed to do so by a customer service representative as well as sent a packet of information along with the request for an external examination to the insurance headquarters of my health insurance to Los Angles, CA and Atlanta, GA like I was told to do so. Three months after the request and in this new year of 2022 when my deductible has reset; I get my denial letter from MES Solutions stating they upheld the denial decision of the insurance company that my surgery would be “investigational”! As I’m looking through their findings I see critical information not in their findings that was the sag way to everything to take place there after; that was in the information they had stated previously they received to do the review. I called MES Solutions and the representative said I had to speak with a nurse about my report. She put in a request for a nurse to call me and said one would call me shortly. Forty-eight minutes later I got a call from a blocked number and it was a nurse. The call lasted fifteen minutes before the nurse hung up on me. During the call I challenged her about the information in the report and what wasn’t put in the report that was apart of one the doctors notes they had in their information. Some of my questions she stated was out of her scope so I said why can’t I speak to a doctor then someone that can answer my questions since you guy’s are medical professionals. You’re saying the procedure is investigational; I feel like you should be able to tell me what is available and not refer me back to my insurance provider. I stated they provide insurance their not medical professionals like you guy’s so you should be able to tell me what can be done. The nurse said she answered to the best she could and that I needed to call the number at the bottom of the report if I had any other problems with the report and she could provide the number if I didn’t have it. I continued to hit her with questions and I did ask for the number but I guess I frustrated her because she hung up on me!

    Looking into complaints online about MES Solutions; I come to the determination that a lot of major insurance carriers maybe not all but a lot of them use this peer review company. It makes you wonder how many thousands of Americans have lost out on much needed treatment do to the apparent “shady” practices of basically being paid off for a report that serves as a “get out of jail free” card for these multi million dollar insurance companies. And as claimants we are left to suffer without getting what the treatment we need to improve our quality of life daily! With all the advances in science and technology nowadays there is no reason why people have to suffer unnecessarily because of the insurance industry in “my personal” opinion is tightly regulated and scrutinized for their practices like they want to send you to this doctor and that doctor and still find a way to not approve coverage or it’s not apart of your explanation of benefits.

    Jeff Jr. Jan 21, 2022  #4

  • Brian, thank you for your comment. We have seen hundreds, if not thousands of reviews conducted by doctors hired by MES. There are doctors that make millions of dollars a year doing these exams for insurance companies. In all of our disability insurance claims we look into the background of the hired Gun doctor and how many times they have been hired by the insurance company. Knowing the background of the hired doctor is a great impeachment tool. It’s important to hire a qualified disability insurance attorney and we are available to help claimants nationwide. Thank you for your comment.

    Gregory Dell May 30, 2020  #3

  • A person had published an in house invoice from MES SOLUTIONS to a national insurance company and the figure for one case was $4,000 for the exam to determine a total disability case. A doctor could work one month a year and live well, if they were to consistently say the worker could return to work or go to partial disability. They have “exams” in non-medical office settings, with no sanitation procedures in place. There is no sink, disinfectant, no tissue put over an exam bed for each patient, in a non-medical lab room. The states should not allow these crooks to run these sham exams, but they would not exist without the unscrupulous insurance companies that hire them. Get a lawyer with a proven track record. Your state has a Legal Bar association that oversees the lawyers in your state and can refer someone, then google them online. The “top lawyers” list that is the list of lawyers for your area that are rated by other lawyers in confidence, is a good source. Google it. It is published every year online and lawyers who make the list will make sure it comes up on an internet search. Insurance companies needs to worry that a lawyer can check to see if someone in the insurance company’s office or at MES( or another similar company) doctored the report to change an honest doctor’s report that agrees with your claim. This was a major issue in New York and fraud investigations were set in place. Having a lawyer who will not be paid until you get paid in a settlement, is your safest choice. There should be no upfront costs. Protect yourself as soon as you file a claim with obtaining a lawyer that is aware of the Insurance companies and their henchmen’s tricks.

    Brian May 30, 2020  #2

  • MES Solutions and Cigna should have class action lawsuits brought against them. There are many of us who have had their disability terminated and denial of insurance claims absconded unlawfully. Poll the numbers and find all of us who needed insurance and disability payment to continue to live. These fraudulent companies have caused suffering and death to thousands of people. I am one of them. Congrats on the Cigna/Mes Solutions Court Case! It gives hope to the helpless.

    Jennifer Jordan-Troklus Oct 26, 2014  #1

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