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Chiropractors Win Class Certification in Lawsuit against Horizon Blue Cross Blue Shield of New Jersey for Improper Benefit Denials

The United States District for the District of New Jersey has certified as a class action a lawsuit brought on behalf of thousands of chiropractic physicians who were denied reimbursement for health benefits by the New Jersey’s largest health insurance company. The three named-plaintiffs, as well as the now certified classes, are represented by the healthcare attorneys at Buttaci Leardi & Werner, LLC, led by John W. Leardi, who serves as co-lead counsel in the case.

In an opinion filed on June 1, 2015, Senior Judge William J. Martini ruled that a two separate classes of chiropractors may proceed with their claims against Horizon Blue Cross Blue Shield of New Jersey and Horizon HMO (collectively, “Horizon”) for systematically denying payment and appeals for evaluation and engagement (“E/M”) and physical therapy (“PT”) services. Horizon concedes that it “bundled” payments for these services into “a global fee” for the chiropractic manipulative therapy (“CMT”), and therefore universally denied separate reimbursement for them. Horizon further concedes that this bundling policy was upheld without exception whenever an affected chiropractor would file an appeal of any such benefit denial.

The lawsuit, captioned Alphonse A. DeMaria, D.C., et al., v. Horizon Healthcare Services, Inc. d/b/a Horizon Blue Cross Blue Shield of New Jersey, et. al., No. 11-cv-7298 (WJM)(MF), asserts claims for violations of the Employment Retirement Income Security Act of 1974 (“ERISA”), as well as state law claims relative to those benefit plans not subject to federal jurisdiction. In 2009, in response to a regulatory complaint filed by the Association of New Jersey Chiropractors (the “ANJC”), the New Jersey Department of Banking and Insurance (“DOBI”) declared Horizon’s bundling practice to be illegal and ordered Horizon to cease and desist beginning in 2010. The lawsuit seeks relief for chiropractic physicians whose claims for benefits were improperly denied by Horizon before the date of the DOBI order.

In his opinion, Judge Martini held that the lawsuit satisfied various preconditions for class certification, such as whether the class members present typical claims and common questions, and whether the answers to those questions would lead to the resolution of the litigation. “In short, this motion poses a simple, concrete question,” the opinion said. “Can the Court fairly and efficiently determine whether the bundling policy violated the rights of the proposed classes? Or do the individual inquiries that will be required to ultimately determine what, if any, actual damages each class member gets, pose such an overwhelming problem as to make class certification impractical and unfair?” In certifying two classes, Judge Martini concluded that the court’s ability to rule on the bundling policy outweighed any arguments that the individual questions for each potential class member would make certification unreasonable.

The DeMaria case is just one of numerous class action lawsuits filed by the healthcare attorneys of Buttaci Leardi & Werner, LLC, throughout the country; all of which aim to protect both patients and doctors from the financial abuses of some managed care companies.

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  • Posted on: Jun 25 2015