A medical clinic in Illinois has sued the NFL in state court, claiming it instructed its insurance carrier to deny those medical claims made by former players, which emanated from that clinic. The claims were made pursuant to the disability plan that was agreed to between the league and the NFL Players Association.
The plaintiff, Advanced Physicians S.C. (Advanced), also accused the league of retaliating against it in a response to the fact that some retired NFL players were using diagnostic tests to claim they had a disability for purposes of a claim.
Advanced began treating NFL Players and their dependents in 2007. The clinic estimates that it has treated more than 200 ex-NFL players between 2007 and the filing of the lawsuit, all as an out-of-network provider.
As part of the agreement negotiated between the league and its players, the clinic was required to forward the medical claim to Cigna Health and Life Insurance Company, which was the sole entity with the legal right to administer the medical benefits covered by the plan.
By 2014, Advanced treated approximately 107 former NFL players or their spouses who were covered under the Plan. The services provided by Advanced included x-rays, MRIs, chiropractic services, physical therapy, physician examinations, pain management services, and orthopedic evaluations. In exchange for the care Advanced provided, each patient executed irrevocable assignment of benefits to Advanced which authorized Advanced to receive payment from the Plan.
Beginning in June of 2015, Advanced discovered that many claims it submitted to Cigna for treatment provided to patients under the Plan were not being processed by Cigna. Cigna told Advanced that all of Advanced’s claims on behalf of patients had been placed with a “random” audit team. When Cigna’s audit of Advanced failed to turn up any irregularities, Cigna changed its course from reviewing Advanced’s billing for medical necessity. Advanced claims it has discovered that the NFL directed Cigna to deny all of Advanced’s claims as work-related. The NFL was upset that some of the retired players Advanced treated were using diagnostic tests provide by Advanced as evidence of a disability under the NFL’s disability plan.
“Because the NFL does not want to pay its former players disability payments under the disability plan, which is funded equally by the NFL member teams, it decided to retaliate against Advanced for providing diagnostic services to former players.”
The complaint notes that in addition to the disability concerns, “the league was also defending itself in multiple lawsuits alleging the league intentionally withheld its knowledge of head injuries sustained by former players. In 2014, the judge in the consolidated cases rejected a proposed settlement between the players and the NFL because the amount proposed for the class was insufficient. Later that same year, a new settlement was reached and approved.
“The NFL does not want independent medical providers like Advanced to treat players and provide independent and honest medical opinions about a player’s brain health. The NFL made the decision to try and economically harm Advanced so that Advanced would no longer treat former NFL players and their dependents.”
Advanced further claims that the NFL’s actions resulted in a decline in player visits, which in turn has resulted in increased operational costs, a loss of financing, and increases in financing costs.
“The NFL does not want independent medical providers like Advanced to treat players and provide independent and honest medical opinions about a player’s brain health,” the suit continues. “The NFL made the decision to try and economically harm Advanced so that Advanced would no longer treat former NFL players and their dependents.”
The plaintiff also alleges “interference with prospective economic advantage.”
Specifically, the complaint reads that “Advanced has a reasonable expectation of entering into a valid business relationship with former NFL players and their dependents. This expectation grew out of Advanced’s multi-year history of treating former NFL players and their dependents.”
The plaintiffs charge that the league “purposefully and intentionally interfered with Advanced’s legitimate expectations by directing Cigna to deny all of Advanced’s claims for payment for medical services as work-related. Because of the interference, the number of former NFL players treated by Advanced has declined every year since 2015.
“The intentional interference with Advanced’s expectations for treating former NFL players and their dependents has caused Advanced economic harm. Advanced has suffered from a decline in patient visits by former NFL players and their dependents. The interference caused Advanced’s credit providers to demand immediate repayment of lines of credit which raised the cost of credit for Advanced, required Advanced to pay for closing fees on new credit lines, and incur professional fees.”