THE CIRCUIT COURT FOR DAVIDSON COUNTY, TENNESSEEAT NASHVILLE

Peter Bonewitz, ) )

Plaintiff, )v. ) CAUSE NO. 14C-4350

)CIGNA Corporation, )Conneticut General Life Insurance Corporation, Inc., Cigna HealthCare of Tennessee, Inc. )Zotec Partners, LLC )

)Defendant, )

)

COMPLAINT

I. INTRODUCTION

1. Plaintiff Peter J. Bonewitz (“Mr. Bonewitz” or “Consumer” or “Plaintiff”) brings

this action against Defendants CIGNA Corporation, Connecticut General Life Insurance

Corporation, Inc., Cigna HealthCare of Tennessee, Inc. and Zotec Partners, LLC and alleges as

follows:

2. For the past 17 years CIGNA health insurance premiums have continuously

soared.

3. CIGNA has been able to artificially influence member premiums through

incentives, strategic claims acceptance, and by exploiting weaknesses in the ICD-9 coding tool.

4. Premiums are based off risk.

5. Risk is based off of the diagnosis codes provided by medical billing companies

like Zotec Partners.

1

6. By strategically accepting cheap labs, imaging (x-rays), and pharmaceutical

claims, contingent on the diagnosis code provided, CIGNA is able to steer how coding is

performed. This process is used to artificially drive up member risk.

7. Coding without physician supervision is resulting in gross inaccuracies of

member data and measurements of risk.

8. CIGNA, by colluding with Zotec Partners, has been able to manipulate the coding

on tens of millions of records and influence risk artificially. Additionally, CIGNA has been able

to influence coding and pass the cost of expensive procedures such as MRIs onto the member.

This can be done through flat out denials or by providing low contract reimbursement rates to

physicians.

9. Zotec Partners, seeking to make the most for its clients and itself, codes in a way

that is most beneficial. It outsources coding to India that is conducted without physician

supervision. Such a process is collusion because it knowingly results in mutual benefit to

CIGNA, the provider network and to Zotec Partners at the expense of CIGNA members.

10. One specific procedure that is artificially driving up risk for CIGNA members is

‘Low-T’, testosterone treatment. This treatment has become extremely controversial because of

its potential adverse side effects and associated risks including heart conditions.

11. CIGNA has made claims and promises through its websites indicating that it cares

about people, their health and that it pursues excellence. Unfortunately CIGNA’s failure to

upgrade to ICD-10 coding, its policies of accepting certain claims such as testosterone treatment

that have become medically controversial, while denying as medically unnecessary physician-

recommended claims such as breast MRI’s12 indicate that CIGNA’s true intent, despite its

corporate face, is sinister and that it is not acting in the best interests of its members.1 http://www.huffingtonpost.com/rebecca-booth/mammogram-at-40-assurance_b_772761.html2 https://community.breastcancer.org/forum/68/topic/801448

2

12. Further CIGNA denies digital tomosynthesis (3D Mammography) breast imaging

stating that it is experimental, investigational or unproven3, while accepting testosterone

treatments even though that treatment also is unproven AND could have hazardous effects.

13. The irony in this is that MRI’s were apparently medically necessary and regularly

accepted up until the timeframe when MRI’s costs began going up45.

14. Shifting costs from expensive MRI’s to testosterone treatments has allowed

CIGNA to become more cost efficient in increasing member risk artificially while also enabling

it to target a different sub-group within its plans to increase risk.

15. Recently a new trend has emerged. Hospital networks have been buying up

private practices at an alarming rate6 . This has led to the huge increase in costs for procedures

like MRIs that are passed on to members.

16. Alan Muney, CIGNA’s chief medical officer, made a statement published for a

Wall Street Journal Article Same Doctor Visit Double the Cost, dated August 27 2012; that

CIGNA believes partnering with hospitals will help lower medical costs.

"Cigna believes partnering with hospitals and physicians…in a model to lower medical costs and improve quality is the best way to manage the widely varying and sometimes very significant physician-practice cost increases we see occur…after a hospital purchases the physician's practice," Cigna Corp.'s CI   % chil officer

17. This published statement by a CIGNA medical authority was deceptive and

mislead Plaintiff. While aligning with hospital networks may help CIGNA to reduce THEIR

costs, significant costs are being passed on to members where they can be paying at a far higher

rate.

3 http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0123_coveragepositioncriteria_mammography.pdf4 http://www.kaiserhealthnews.org/stories/2012/december/09/mri-cost-price-comparison-health-insurance.aspx5 http://online.wsj.com/news/articles/SB100008723963904437137045776011136710074486 http://online.wsj.com/news/articles/SB10000872396390443713704577601113671007448

3

18. Zotec Partners has played a shadow role in fulfilling CIGNA’s needs by providing

the coding that CIGNA wants while also making the most money for its provider clients. Zotec

Partners’ ability to conceal itself from CIGNA members while preventing accurate resolution of

medical billing disputes is a primary reason that consumers become mired in medical debt while

CIGNA has enjoyed the good fortune of billions in profits over the past several years.

19. Together, CIGNA and Zotec Partners’ unscrupulous methods have made

disputing medical bills enormously complex and convoluted with the intent of placing an

unnecessary burden on CIGNA members, resulting in tremendously unfair damages.

20. A former employee of both companies, Plaintiff discussed the concerns of fraud

with Zotec Partners and CIGNA representation and both failed to respond to or address the

factual allegations except, in Zotec’s case, indicating that their behavior is no different than other

medical billing companies. CIGNA had a fiduciary duty to respond in a transparent way.

A. JURISDICTIONurisdiction

21. Venue is proper in this judicial district as Plaintiff held insurance and resided

within the jurisdiction of the Circuit Court for Davidson County at Nashville when the unlawful

actions took place.

22. This Court has personal jurisdiction over Defendants because they conduct

business in this District, and the unlawful conduct alleged in the Complaint occurred in, was

directed to, and/or emanated from this District.

4

23. Venue is proper in this District under 28 U.S.C. § 1391(b) because a substantial

part of the events or omissions giving rise to the unlawful conduct alleged in the Complaint

occurred in, was directed to, and/or emanated from this District.

B. PARTIESParties

24. Plaintiff Peter Bonewitz is a natural person and currently a citizen of the State of

Indiana Hamilton County, and City of Carmel.

25. Defendant CIGNA Corporation is a corporation existing under the laws of the

State of Connecticut with its principal place of business located at 900 Cottage Grove Road,

Bloomfield, CT 06002. CIGNA Corporation conducts business throughout this District, the

State of Tennessee, and the United States. CIGNA Inc. is registered with under the Business ID

0131036XXX as entity number 310000xxxxx. Additionally, it is registered as a Health Insurance

Business (“HIB”) to conduct HIB Activities in the State of Tennessee.

26. Defendant Cigna HealthCare of TennesseeConneticut General Life Insurance

Corporation, Inc. is a corporation existing under the laws of the State of Tennessee with its

principal place of business locatedregistered at 500 JAMES ROBERTSON PKWY800 S. Gay

St. Ste 2021, NASHVILLE, TN 37243Knoxville, TN,. Cigna HealthCare of Tennessee, Inc.

conducts business throughout this District, the State of Tennessee, and the United States.

Connecticut General Life Insurance Corporation, Inc. HealCigna Inc. is registered with XXX

asund companyntrol number 605731000145909 entity number 310000xxxxx. Additionally, it is

registered as a Health Insurance Business (“HIB”) to conduct HIB Activities in the State of

Tennessee.

27. Defendant Zotec Partners, LLC is a limited liability corporation existing under the

laws of the State of Indiana with its principal place of business located at 11460 N. MERIDIAN

5

STREET, XXX Carmel, IN 46032. Zotec Partners, LLC Inc. conducts business throughout this

District, the State of Tennessee, and the United States. Zotec Partners, LLC is registered with

XXX as entityunder control number 2007032900534310000xxxxx.

Factual Allegations

II. NATURE OF THE ACTION

28. 22. Substantial premium increases78 by CIGNA has helped to reveal exploitive

profit taking 91011 iin a mammoth industry and it has exposed a massive scheme to defraud millions

of consumers by means of artificially increased risk.

29. 23. Unfortunately, while it is easy to buy insurance it has been very difficult

for consumers to prevent rate increases, dispute false claims or have control over how their risk

is fairly measured.

30. The inability to challenge denied claims12, false claims, or the accuracy of a

diagnosis code could cause risk to artificially rise while saving CIGNA money.

31. Charging members premiums based on an artificial projection of costs would

mean that members are not getting the care for which they are paying. They would be paying at

an inflated rate.

32. CIGNA has been able to artificially influence risk and manipulate premiums in

several ways; exploiting weaknesses in the antiquated ICD-9 Coding System incentives, and

strategic acceptance of medical billing claims. 7 http://www.cnn.com/2010/POLITICS/02/18/health.insurance.rates/8 http://www.nytimes.com/2011/09/28/business/health-insurance-costs-rise-sharply-this-year-study-shows.html?pagewanted=all&_r=09 http://www.rttnews.com/1995648/CIGNA-lifts-full-year-profit-forecast-as-q3-earnings-soar.aspx10 http://www.hartfordbusiness.com/article/20140501/NEWS01/140509998/CIGNAs-1q-profits-soar-on-premium-fee-growth11 http://abcnews.go.com/Health/HealthCare/health-insurers-post-record-profits/story?id=981869912 http://www.disabled-world.com/disability/insurance/claims/CIGNA-denied.php

6

33. Zotec Partners has coded in a way that CIGNA wants through a process of

collusion which violates the consumer.

III. INTERNATIONAL CLASSIFICATION OF DISEASES AND HEALTH PROBLEMS

34. International Classification of Diseases (ICD) is the international “standard

diagnostic tool for epidemiology, health management and clinical purposes.” 13 The ICD is

maintained by the World Health Organization, the directing and coordinating authority for health

within the United Nations System. The ICD is designed as a health care classification system,

providing a system of diagnostic codes for classifying diseases, including nuanced classifications

of a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and

external causes of injury or disease. This system is designed to map health conditions to

corresponding generic categories together with specific variations, assigning for these a

designated code, up to six characters long. Thus, major categories are designed to include a set of

similar diseases.

35. The International Classification of Diseases is published by the World Health

Organization (WHO) and used worldwide for morbidity and mortality statistics, reimbursement

systems, and automated decision support in health care.

36. There are different ICD versions. The current version, ICD-10, was developed in

1992 and contains approximately 68,000 diagnosis codes and is expandable with characters.

37. The outdated version, ICD-9, which uses just 5 digits contains only about 13,000

diagnosis codes. This limitation gives it far less scope and specificity compared to ICD-10.

38. T Thehe inherent lack of scope and specificity of ICD-9 compared to ICD-10

prevents one from getting accurate statistics and measurements of data compared to ICD-10. A

13 http://en.wikipedia.org/wiki/International_Statistical_Classification_of_Diseases_and_Related_Health_Problems

7

general example on specificity: Pain in Arm versus Bee Sting in Left Arm. Pain in arm lacks

specificity and therefore has much broader risk implications (such as heart disease); whereas bee

sting in left arm is very specific and allows for far greater accuracy when measuring risk and

costs.

IV. ZOTEC PARTNERS (MEDICAL BILLING COMPANY)

39. Zotec Partners is one of the largest—if not the largest—medical billing company

in the country that conducts medical billing for major clients including radiology groups,

radiology associates, anesthesiology associates, anesthesiology groups, radiology providers,

pathology providers and emergency room providers.

40. In 2013 Zotec Partners acquired Medical Management Professionals (MMP) for

$200 million. MMP provides similar medical billing services and specializes in emergency room

visits.

41. While the companies had roughly matching revenues Zotec Partners employed

approximately 350 people which is about one quarter of the personnel employed by Medical

Management Professionals.

42. The territories of the combined businesses include MidWest, SouthWest, West

(Zotec Partners) and South East and Mid-Atlantic (MMP) with concentrations in areas that

include Tennessee, Texas, Florida, Georgia, California, Nevada, Illinois and Indiana among

other states. Several of these states are known to have high concentrations of fraud.

43. Zotec Partners earns its revenue based on billing the client a percentage of the

total revenue collected. Its revenue is a small fraction of the revenue generated for its clients.

8

44. The fact that Zotec Partners specializes in radiology and services the largest

clients in the industry means that it can be highly influential on increasing the risk of CIGNA

members based on the diagnosis codes used.

V. CIGNA HEALTH INSURANCE

45. CIGNA is one of the world’s largest health insurance companies where

individuals from different markets can purchase health insurance.

46. CIGNA provides many different health insurance offerings through business

group plans as well as private plans. There are high and low deductible amounts with different

premiums based on the offerings in the plan.

47. Through its public marketing and representation1415 on its corporate websites

CIGNA makes the following statements: “For more than 200 years CIGNA has helped people

live healthier and more secure lives,” “It is one of the leading health organizations in the world,”

“We care about the people,” “We demonstrate courage,” “We act with integrity,” “We are

committed to Excellence,” “help keep people well,” “treat our customers with respect and

dignity.”

48. These written promises are complemented by images including a person cradling

an apple, a mother happily cherishing her daughter, a person blowing on a dandelion, and

another image from the point of view of a parent watching a child in bed hugging her dog.

49. The images presented, along with the language used, convey that CIGNA is

looking out for us and our best interests when it comes to our health care as though a parent

would look out for their own child. Ironically, all of these statements and images were only

displayed on CIGNA’s foreign facing (European) websites. Nevertheless, they are corporate 14 http://www.CIGNAeurope.com/contactus.html15 http://www.CIGNA.be

9

statements about CIGNA’s belief system and are promises to all of its members, foreign or

domestic.

50. CIGNA also claims that it is “working to minimize healthcare fraud.”16

51. It states “Our Corporate Audit Department’s Special Investigations (SI) team is

responsible for minimizing CIGNA’s risk to health care fraud. The SI team partners with

CIGNA’s Customer Service Claim Centers and others to help identify suspicious claims, stop

payments to fraudulent providers and punish wrongdoers.”

52. Unfortunately for consumers, CIGNA has seriously failed to deliver on its

promises, breached trust and eroded the value of the health care provided.

VI. UNETHICAL CONDUCT, VIOLATIONS AND DECEPTION

53. Over the past several years CIGNA has developed a consistent pattern of

unethical conduct, unscrupulous behavior and deceit. Such behavior violates the trust of its

members and has eroded the integrity of the health care that CIGNA provides. This behavior

includes charges and fines by states for the following: failing to respond to consumer complaints

in a timely manner17, failing to accurately and consistently calculate premium rates18,

overcharging drug co-pays19, inflating prescription drugs costs20, hundreds of wrongful denials of

16 http://www.CIGNA.com/reportfraud/17 http://www.badfaithinsurance.org/reference/General/0429a.htm18 http://www.bizjournals.com/triangle/news/2011/03/25/CIGNA-to-pay-600000-north-carolina.html19 http://www.delawareinsurance.gov/departments/news/092007-Press-CIGNAfined.shtml20 http://www.businessinsurance.com/article/20080803/ISSUE01/100025560#

10

nutrition counseling21, , systematic claims processing issues2223, failure to market a low cost health

plan24, down coding and non-payments to physicians2526, and other offenses.

54. Other ethical concerns that have been brought forward include: high rate of

denied claims27, a recent class action by the chiropractor association for improper practices 28 and

suspect pull through arrangements with laboratories2930 . Pull through arrangements allow special

rates in exchange for high volume. By strategically accepting lab claims based on the diagnosis

code provided CIGNA can manipulate risk in order to influence premiums. The pull through

arrangements attracted the attention of the Office of the Inspector General (OIG) and The United

States Senate.

55. In addition CIGNA falsified the pay of its CEO, David Cordani, in information

provided to the State of Vermont for data intended for public consumption, making it appear as

though he earned a small fraction of the true amount31. The fact that Cigna made a false

statement for public consumption regarding such an innocuous and simple fact caused plaintiff to

doubt all facts that are presented publicly by Cigna, including claims denials and the

trustworthiness of how it gathers and interprets data.

56. CIGNA has shielded its influence and has failed to disclose its financial

involvement in funneling $100 million to the Chamber of Commerce in 2009 and 201032 through

21 http://www.ag.ny.gov/press-release/ag-schneiderman-announces-settlement-health-care-insurer-wrongfully-denying-mental22 http://www.erisaclaim.com/CIGNA%20settlement.pdf23 http://www.hmosettlements.com/settlements/CIGNA/CIGNASettlementAgreement1.pdf24 http://www.managedcaremag.com/archives/9809/9809.states_coloradofines.html25 http://www.amednews.com/2004/05/10/prra0510.htm26 http://www.californiainsurancelitigation.com/news/californias-largest-health-insurers-are-fined-by-california-department-of-managed-health-care-for-in/27 http://vtdigger.org/2013/05/19/CIGNA-leads-vermont-health-insurers-in-denied-claims/28 http://www.acatoday.org/press_css.cfm?CID=508129 http://www.grassley.senate.gov/sites/default/files/about/upload/David-Cordani.pdf30 http://www.amednews.com/article/20111121/government/311219954/6/ 31 http://vtdigger.org/2013/05/19/cigna-leads-vermont-health-insurers-in-denied-claims/32 http://www.publicintegrity.org/2013/04/29/12581/opinion-insurers-hiding-political-spending

11

the trade group Americas Health Insurance Plans (AHIP). Discovering this lack of transparency

and evading the concerns, further eroded Consumer’s trust.

57. CIGNA, a publically held company, has been able to conceal their internal

conduct from the public with the intent to defraud and prevent civil action through Compliance,

corporate attorneys, massive severances33343536, and wrongful termination action37.

58. Unfortunately this vital negative information, which would have impacted

Consumer’s decision in determining whether to trust CIGNA to handle his health care needs,

was pushed out of public consciousness in search engines. None of it exists within the first 10

results pages of a Google search on the word CIGNA.

59. CIGNA, through the creation of many company social sites (Twitter, You Tube,

Facebook), press releases, foreign sites and web pages, has boosted its own public image while

simultaneously suppressing any negative information. This includes published news by concerns

ranging in size from the State of New York38 to consumer complaints on small forums.

60. Such deceptive and identifiable search engine optimization techniques, known as

reverse SEO, is unethical when used for this manner because it deceived the Consumer about the

company’s business practices. Such a process deceived the Consumer because he would expect

important and relevant information related to the company, such as a lawsuit, to show up in the

top few pages of search results. However, not a single lawsuit or violation appears in the first 10

search results pages.

33 http://www.amednews.com/2010/09/13/birb0913.htm34 http://articles.courant.com/2012-03-05/business/hc-CIGNA-executive-pay-cordani-20120305_1_option-awards-ceo-david-m-cordani-theoretical-value35 http://www.huffingtonpost.com/2010/03/20/CIGNA-gives-1109-million_n_506974.html36 http://articles.courant.com/2009-05-27/news/CIGNA-bell.art_1_CIGNA-corp-bell-s-departure-michael-w-bell37 http://www.law360.com/cases/52d70c8b68f52d3f86000001 38 http://community.babycenter.com/post/a49187680/anyone_have_infertility_benefits_with_CIGNA

12

61. In addition to ethical concerns of its internal operations there is deep concern that

CIGNA has recently engaged in outsourcing some of its operations in order to deceive

consumers while concealing its business practices. These operations include: Provider Benefits

Management (PBM) for behavior management and pharmaceuticals and Specialty Health Care

Management.

62. Recently CIGNA aligned itself with American Specialty Health (ASH), a

privately held company which provides a growing form of care called Specialty Health Care

Management.

VII. AMERICAN SPECIALTY HEALTH

63. American Specialty Health’s roots began in 1987 in Southern California as a

chiropractic and acupuncture network. It relocated its expanded corporate headquarters in 2010

to San Diego, the same year Obamacare passed. ASH has grown enormously and has been

named in Inc’s Fastest Growing Companies for the past three consecutive years. It is now

relocating operations to Carmel, Indiana where Zotec Partners has its headquarters.

64. American Specialty Health claims to be “changing paradigms,” “improving the

quality of healthcare,” “improving clinical outcomes and bending the cost curve” by offering

different health management programs to improve the health of employees.

65. They claim to infuse work practices with honesty, integrity and ethics. Many

consumers and former employees appear to highly disagree with that statement.

66. American Specialty Health has a one star rating on the online business review site

Yelp as a result of input from former employees, medical billers and consumers regarding

dishonesty, deceit and unethical practices. Not one single good review. There are many

additional complaints against American Specialty throughout the web. Here is a representative

sampling of comments on Yelp.

13

“This company is basically a gatekeeper for certain insurance plans. They sponge the money off the top, burden the physicians and medical providers with worthless and unnecessary red tape and total nonsense, and basically steal money from patients and doctors.”

“This company needs to be removed from the insurance system. They will not address any issues from an honest standpoint. When you catch them in a lie they just won’t respond. I think we need to take a class action suit against them. All the practitioners that I know hate them. they are also not abiding by the Affordable Health Care Act. They are not supposed to discriminate against doctors for office visit pay outs. When i brought this up with their office they just ignored me.”

“Probably one of the worst companies I have ever dealt with.   They have taken over much of the claim processing for chiropractic care claim processing for CIGNA, Blue Cross etc.   All is ok after 5 visits but after that, it gets flagged even though the insurance plan covers up to 30.  They were rude to my wife.”

“Awful Awful AWFUL! I would give it negative stars if that was an option. I’ve worked as a medical biller for years, and this is the worst, most inefficient, pathetic excuse for a company that I'’ve ever dealt with in my life! I HIGHLY advise anyone who needs reliable health insurance to steer clear of this company! Make sure the insurance you sign up for is in NO WAY, SHAPE, OR FORM associated with ASH!”

“In the last year, they have not processed one single claim correctly from our office and have left our poor patients with extremely high balances, fraudulent EOBS, incorrect benefits, and straight out lied to providers and patients. They have no phone number for their “claims department” and I can only assume that is because the loosely trained monkeys there are not capable of answering phones yet.”

“Their customer service is joke - count on them not taking responsibility for their actions, pulling some excuse out of their ass about how the problem is actually *YOU'RE* fault, and an endless amount of other lies and incorrect information. Seriously: try calling them 10 times about the same issue and listen in amusement at the ten different answers you get. Oh, and don’t believe them when they say “I'll forward this to my supervisor and get it taken care of” because that will literally never happen. In fact, I’m pretty positive they don’t even have computers there and their headquarters is actually just a bunch of children roaming around empty rooms with telephones.”

“Try googling the lawsuits they consistently have against them – it’s baffling to me they are even still considered a “company.” I can only hope the government eventually shuts down this clown show and gives patients the care they DESERVE and PAY FOR EVERY MONTH! This company is a toxic mix of incompetent retardation and insurance fraud at it’s finest.”

14

“This is one of the worst and most predatory companies in all of healthcare.  They force their doctors to do pages and pages of paperwork to get a few bucks.  Hopefully the new MLR rules cause this company to lose millions of dollars.”

“I worked at this Mickey Mouse operation just over 6 months as a Sr. Software Engineer and resigned.”

“Their IT management is a complete joke; their CIO and his assistant director side-kick couldn’t program themselves out of a paper bag! This company is so backwards they do their testing on production relying on the consumers to find bugs for them!”

“I documented everything making sure they weren’t able to put the blame on me for their project failures! I see why they’re having tremendous difficulty recruiting .Net developers! Cracker-jack mentality at its best!”

“This place is a crock. They treat their employees like they are 8 year olds that misbehaves. There’s no means of advancement here. …when you have a patient that is used to a certain coach that is no longer there because management feels that it is best to restructure the system without said coach, that patient is ultimately going to fail….”

“Just terrible all around. Nothing good to say about this company. They take advantage of people who are trying to provide a service to the public. They don’t manage care they strangle it to death. Good luck ASH! You're the worst type of company.”

“As an former employee in customer service level 2, I would not recommend this place unless you are in dyer need. Coworkers great, ceo/president could care less how many people you help or who he has not helped. Its all about the $. So if you can lie go for it!!”

“This is the worst run company I have ever had to deal with, George DeVries and Bob White are so unprofessional and their employees are so rude and NEVER return phone calls. I’m so glad I have other choices, and that I will never have to deal with this company ever again.”

67. Ironically, American Specialty Health and CIGNA were sued by the American

Chiropractors Association39 in late 2012 for several allegations including:  

“…arbitrary reductions of care, lack of communication to providers and patients resulting in coverage and payment errors, interference with doctors’ duty to exercise professional clinical judgment in managing patients’ treatment plans, Manipulating charge and payment data, allowing ASHN and CIGNA to pass on excessive costs to subscribers, imposition of excessive co-pay requirements on subscribers (ERISA violation), ASHN’s restrictions of care via the pre-authorization process and provider contract provisions that

39 http://www.acatoday.org/press_css.cfm?CID=5081

15

prevent patients from having access to the full breadth of their benefits and in contradiction to their certificates of coverage (ERISA violation).”

68. CIGNA’s history of charges and fines for unethical behavior, class action suits,

and partnerships with questionable privately-held companies like ASH, reflect an undeniable

intent to deceive the Consumer. This is bad for health care. They have broken the trust with

Consumer and have eroded the value of health care and the premium.

69. CIGNA’s former VP of Corporate Communications4041 and author of the book

“Deadly Spin”, Wendell Potter, has become the industry’s loudest critic on its use of spin and

deception.

VIII. FAILURE TO CARE

70. The following are six of 294 comments42 from the consumer advocacy website

ConsumerAffairs.com. CIGNA has an average rating of 1 star. These comments further indicate

a breach of promise by CIGNA in its failure to care about people, help keep people well and its

commitment to excellence. (See exhibit X for full comments).

Anne of Hopewell Junction, NY: “I am a healthcare provider and without a doubt the worst insurance company I have ever had to deal with…They are AWFUL. Steer clear.”

Eileen of Monroe, CT: “I have had CIGNA for approx 15 years and EVERY claim is an ordeal. In 2012 I filed a complaint with the AG of CT as well as the Ins. Board, yet nothing changes. How much does make illegally by purposefully denying aspects of every claim? CIGNA, in my experience and opinion, is a shady operation at best.”

Can’t read name/address: “CIGNA will do anything they can to prevent you from getting an MRI. Their customer care was absolutely useless. I have spoken to several co-

40 http://wendellpotter.com/41 http://www.publicintegrity.org/health/wendell-potter?gclid=CJW4hv6i5sACFbRzMgod7gYAhw 42 http://www.consumeraffairs.com/insurance/CIGNA_health.html

16

workers, and not a single one has been able to get an MRI through CIGNA, either. My company (global: 60,000+ employees should flush them down the toilet.”

Rose of Hyde Park, NY: “My doctor is refusing to see me as a patient because CIGNA Insurance has not paid for a single one of the claims he has submitted. I was force to go home (from hospital) with a life-threatening medical condition, unable to walk or take care of myself.”

Maria of Old Bridge, NJ: “Consistently rejects pre-approved claims…Eventually they pay, but I have to waste my time playing this cat and mouse game. Depending on who I speak to, I consistently get different information.”

Lise of Chicago, IL: “I am a healthcare provider. I’ve had one bad experience after another with CIGNA. They are either incompetent, dishonest or both (probably the latter). I submitted timely claims, which they repeatedly sent back to me as “illegible.” The submissions were as legible as a stop sign. I resent them multiple times. Finally they accepted the claims but denied payment due to “untimely filing.” How’s that for a scam?

VIIIX. FRAUD THROUGH ARTIFICIALLY INCREASED PREMIUMS

71. In a general sense health insurance premiums are based on the perceived risk of

the member group. In order to determine the group’s risk, an individual such as an actuary,

would analyze the ICD-9 diagnosis codes and the mortality risks associated with them.

72. By aggregating the risks of the member group the actuary can make projections

on future costs so that premiums can be determined.

73. The accuracy of the diagnosis code used is therefore crucial in determining risk

assessment and premiums.

74. Unfortunately, CIGNA has been able to influence and have control over this

process. CIGNA has been able to guide procedure volume, manipulate the diagnosis code

selection and influence risk in order to make premiums go up artificially.

75. Over the past 20+ years CIGNA has been using an antiquated ICD-9 coding

system throughout its private provider network. ICD-9 lacks both specificity and range. A lack of

17

range could cause conditions to be polarized. A recent article highlights ICD-9’s shortcomings43:

Specificity, Scope, Accuracy and Completeness. ICD-9 lacks the capability to accurately reflect

conditions compared to ICD-10. Therefore, risk and future costs are less accurate for ICD-9

compared to the capabilities of ICD-10.

76. CIGNA has been able to guide medical coder behavior by strategically accepting

and denying medical codes so that risk becomes negatively skewed and risk increases.

77. Increased premiums based on artificial risk would mean that the premium price is

being inflated.

IX. CONTRACT INCENTIVES

78. One of the ways that CIGNA can guide risk artificially is through incentives that

can increase the volume of certain procedures.

79. Based on evidence discovered by Plaintiff, CIGNA appears to be condoning the

use of complex incentive contracts through a series of partnerships that obfuscate and shield

CIGNA and the Provider Group. The intent of these contracts is to incentivize referrals for

procedures to be performed (such as chest X-Rays) or prescriptions to be prescribed (such as

Abilify).

80. By increasing the volume of procedures, through incentives CIGNA has the

ability to guide risk throughout its membership base.

XI. PHARMACEUTICAL INCENTIVES

81. 52. In addition, based on discovery by Plaintiff through his

employment, CIGNA has been tracking the pharmaceutical use of its members including

43 http://cielomedsolutions.blogspot.com/2009/02/shortcomings-of-icd9-and-billing-data.html

18

pharmaceutical type, physician, volume, pharmacy and other data and passing it to the

pharmaceutical manufacturer in order to receive “rebates.” Such actions, without the member’s

knowledge, are a breach of fiduciary duty and trust. It allows the manufacturer to pass incentives

through sales agents back to physicians without the consumer’s knowledge. This would likely

drive up pharmaceutical use.

82. Providing pharmaceutical data to the manufacturer is very self-serving. It

incentivizes CIGNA to condone and encourage pharmaceutical use. The diagnosis codes

associated with pharmaceuticals can help drive up risk artificially (and cheaply) while CIGNA

also receives kickbacks on volume purchases at the expense of the consumer.

XII. TESTOSTERONE TREATMENT

83. Testosterone treatment is a controversial industry that has come under scrutiny

regarding medical necessity. The provision of male testosterone treatment to those who need a

“boost,” while women are often declined potentially lifesaving breast MRIs or fertility

treatments, draws into question the ethics of healthcare and how CIGNA is determining medical

necessity.

84. Despite the lack of evidence for medical need, the testosterone industry has grown

enormously over the past several years. Doctors have warned that demand for treatment could

lead to deadly side effects44.

85. Low serum ‘T’ levels, are linked to several severe morbidity issues including:

obesity, cancer, fractures, falls, cardiovascular disease, diabetes mellitus, Alzheimer’s, metabolic

syndrome and total mortality4546, despite the fact that lab tests and diagnosis can be faulty.

44 http://mobile.bloomberg.com/news/2012-05-02/testosterone-chases-viagra-in-libido-race-as-doctors-fret.html45 http://eurheartj.oxfordjournals.org/content/early/2010/02/17/eurheartj.ehq009.full46 http://www.medscape.org/viewarticle/575491

19

86. According to recent research published in the New England Journal of Medicine47

and other highly respected periodicals4849, Testosterone treatment has been linked to serious heart

related side effects including stroke and heart attacks5051 making treatment potentially very

harmful to patients who do not need it.

87. Additionally, there is no evidence that ‘Low–T’ treatment helps these mortality

issues in any way52..

88. CIGNA is unnecessarily endangering its members by accepting testosterone

treatments when other tested options are available. There is no evidence that indicates that

testosterone treatment is beneficial to one’s health and yet there IS evidence that it is linked to

heart related conditions. In fact, a known side effect is low sperm count and infertility53.

89. Using substantial health care funds for controversial ‘Low-T’ treatment

wrongfully exposes members to risks while also denying more important care that could have

been provided to other members (such as cancer treatment or surgery) had the monetary

resources been available. This is unfair to the members. The primary concern is that absent

medical necessity ‘Low-T’ treatments could be used to artificially increase member risk and

premiums by taking advantage of faulty and unreliable diagnostic methods.

90. Confusion by untrained coders54, who are forced to decide the diagnosis code

using an inadequate ICD-9 coding system, will lead to false claims as demonstrated in forum

post comments.

47 http://www.nejm.org/doi/full/10.1056/NEJMoa100048548 http://www.mayoclinic.org/healthy-living/mens-health/expert-answers/testosterone-therapy-side-effects/faq-2009001549 http://www.nih.gov/news/health/jun2010/nia-30.htm50 http://www.drugwatch.com/testosterone/heart-attack/51 http://www.webmd.com/men/news/20140129/testosterone-therapy-might-increase-heart-attack-risk-study52 http://www.medscape.org/viewarticle/57549153 http://www.webmd.com/men/features/infertility54 https://www.aapc.com/memberarea/forums/showthread.php?t=15188

20

91. Lumping such a broad spectrum of people into one class, Male Hypogonadism

(257.2), based on lab tests and diagnostic processes known to be faulty, would falsely

exaggerate the health conditions of a wide range of people. This could make risk skyrocket.

92. The scholarly article points out several interesting facts. First of all, that patients

should be tested in the morning for accurate levels and that they should be tested multiple times

due to variance. Also the patient should not be sick, and should not have been working out hard,

or have been using recreational drugs because these factors can reduce T-Levels. Finally, a

careful history and clinical evaluation is needed to exclude these conditions. Most importantly,

however, is the statement that there is NO threshold T-Level because it varies among age and co-

morbid conditions. This means essentially that treatment is left open-ended to the feedback of the

patient. Unfortunately that feedback by the patient can lead to many false diagnoses.

93. Furthermore this article indicates that because there are no effective screening

strategies, screening for the general population is not justified.

94. CIGNA is able to take advantage of its member network by letting the

testosterone patients themselves determine what is medically necessary. These testosterone

patients are potentially taking risks with their own health in order to feel a “vitality boost”

because the treatment has become so widely available.

95. CIGNA may also be condoning the ‘Low-T’ treatment in order to receive

kickbacks for volume sales from the pharmaceutical manufacturer.

96. ‘Low-T’ Testosterone treatments give CIGNA the ability to exploit faulty

diagnosis and weaknesses in the ICD-9 coding tool, specifically Male Hypogonadism (257.2).

This ICD-9 diagnosis code was created far before treatment became widely popular and cannot

possibly reflect the range of different ‘conditions’ that exist in the general population.

21

97. Strategically accepting claims for Male Hypogonadism or ‘Low-T’ based on

known unstable testing and interpretation methods, and using a faulty and inadequate coding

system, could create a false picture of a member’s true health and make premiums rise artificially

for an entire group of members. This would mean that all members including Plaintiff are

paying at an inflated rate.

XIII. FACTS RELATING TO PLANTIFF PETER BONEWITZ

98. In early 2012 as part of consideration of becoming an employee at CIGNA and a

member of its health plan, Mr. Bonewitz read through its public facing corporate websites and

online representations regarding CIGNA’s services, including the representations: “We care

about the people,” “We demonstrate courage,” “We act with integrity,” “We are committed to

Excellence,” “help keep people well.” CIGNA’s representations indicated that CIGNA would

provide ethical health care and look out for his family’s best interests. This was substantially

similar to the advertisements and representations described in section V above. In addition, this

was substantially similar to internal “corporate speak” used by CIGNA executives during

conference meetings.

99. During his Google search of CIGNA, which was limited to the first three results

pages, Plaintiff saw no information that contradicted the ethics that CIGNA portrayed in its

websites.

100. Relying on those representations, Mr. Bonewitz became an employee and also a

member of its CIGNA health plan for seven months.

22

101. Mr. Bonewitz paid premiums in exchange for ethical health insurance coverage

that provided health care that was supposed to be in his family’s best interest and ahead of

CIGNA’s own self-interest.

A. XIII. EXPLOITING TESTOSTERONE TREATMENTS, FAULTY LAB TESTS AND

ICD-9

102. In approximately June 2012 while Plaintiff was an employee and member of

CIGNA’s health insurance plan he began receiving testosterone treatments over a period of

several months that had little to no measurable impact.

103. Plaintiff had his bloodwork done in the late afternoon while he was recovering

from a sinus infection, had been working out intensely on a regular basis and had no working a/c

in his upstairs apartment during a hot summer. In addition he had not eaten for most of the day.

He was not aware that one of these factors or a combination of the factors (including a low

immune system) could influence testing. Plaintiff was clear and straightforward with the medical

practitioners with regard to all of his conditions during his examination.

104. Clinic was clear with patient that he was borderline and that he could try the

treatments.

105. Clinic explained before treatment started that by getting off the treatment it could

take some time to get back to ‘normal’ and so member delayed stopping the treatment for this

reason.

106. Prior to using the Low-T clinic he had chosen, Plaintiff had visited and had blood

testing at another clinic. This clinic had less physician involvement and the interaction was with

an assistant and had the impression of more of a sales pitch. Again the blood test was done in the

23

late afternoon and there was no issue getting treatment or having the claim submitted for

insurance coverage through CIGNA.

107. Through his employment with CIGNA Plaintiff grew concerned abut the

company’s ethical conduct and specifically why it accepted his claims for testosterone treatment

as medically necessary despite the fact that the clinics were not following advised protocols. This

included: not taking multiple blood tests in order to determine an ‘accurate’ average of

testosterone levels; not telling patient to hold off until sinus infection was gone; and not having

the patient take the lab test in the morning when T-levels are higher. Allowing the test to be

consistently done in the afternoon could negate the validity of the tests.

108. Plaintiff believed that CIGNA was allowing these processes because they helped

artificially increase risk. Plaintiff did not believe his circumstances were unique. In fact, ‘Low-T’

centers were suddenly opening in many locations and there was even online advertising for

getting ‘Low-T’ treatment.

109. By accepting testosterone claims and not requiring or enforcing certain standards,

CIGNA would enable the testosterone market to grow enormously.

110. Plaintiff came to the conclusion that male members were being duped (including

himself) thinking that CIGNA was being generous paying for testosterone treatments while other

members can’t get claims, like disability benefits, paid.

111. Plaintiff believed, based on this experience and his previous experiences and

knowledge, that CIGNA was accepting and paying the claims not out of medical necessity or

generosity, but in order to artificially increase risk and raise premiums for everyone.

XIV.B. CONCERNS OF FRAUD RAISED TO COMPLIANCE AND ATTORNEYS

24

112. While employed as a business intelligence analyst Plaintiff raised specific

concerns to CIGNA Compliance and attorneys both verbally and in written documents based on

information he uncovered. These concerns related to: contract incentives; deliberately not

looking for certain types of fraud that increases risk; sharing member data with pharmaceutical

manufacturer; concealing kickbacks received from the pharmaceutical manufacturer; strategic

claims acceptance; ICD-9 coding system; testosterone treatment; and fiduciary obligation to

members.

113. Additionally, Plaintiff brought concerns to CIGNA regarding it being complicit in

medical billing fraud. Plaintiff indicated in a multi-page document to Compliance and CIGNA

attorneys that his former employer, Zotec Partners, the largest medical billing company in the

country, had processes that made disputing claims extremely challenging. This included:

outsourcing coding to India where the process used to code was unknown; using untrained

interns without physician interaction; phone representatives who took no notes; and a lack of

system logging which prevented the ability to track or handle consumer disputes properly.

Plaintiff indicated that prevention of disputes can result in consumers giving up and paying out

of fear that their credit will be damaged, whereas CIGNA faces no such concerns for non-

payment.

114. Plaintiff indicated that if CIGNA was in fact incentivizing certain procedures to

increase risk then this could encourage the medical billing company to commit false claims and

prevent disputes. Additionally, Plaintiff indicated that if CIGNA offered low reimbursements for

certain processes, then this could encourage the medical billing company to falsely code the

claim so that the member absorbs the cost. Plaintiff indicated to CIGNA Compliance and

attorneys that it had a fiduciary duty to its members to be looking out for them as it relates to the

wrongful practices of medical billing companies because 1) CIGNA is an expert in healthcare

25

industry 2) they decide the providers in the network 3) CIGNA has control over risk and

premiums 4) members cannot look out for themselves in such a complex industry.

115. CIGNA attorneys flew out to meet Mr. Bonewitz and discuss his concerns of

fraud. Specifically they repeatedly requested to know what evidence he had. Mr. Bonewitz

shared with CIGNA all of his concerns. CIGNA’s attorneys claimed that an investigation would

be conducted and assured Mr. Bonewitz that the proper legal steps would be taken.

XV.C. ATTORNEYS ISOLATED BONEWITZ FROM SUPPOSED INVESTIGATION

116. Instead of involving Mr. Bonewitz, CIGNA isolated him from whatever

investigation it purported to be conducting regarding his fraud concerns. Isolating Mr. Bonewitz

was unusual given the fact that he was a level III analyst working in the Business Intelligence

department and that there was no reason for a public company to conceal their investigation from

the employee. Additionally, CIGNA’s attorneys isolated Mr. Bonewitz from working with the

Compliance officer which would have enabled an effective and transparent investigation process.

XVI.D. MAJOR FBI/MEDICARE FRAUD BUST OF CIGNA/HEALTHSPRING

PROVIDERS

117. During Plaintiff’s time of employment with CIGNA a major nationwide

FBI/Medicare fraud bust55565758 occurred. Several of the providers under investigation were

providers for his employer. Mr. Bonewitz brought this information to the attention of CIGNA’s

55 http://www.cnbc.com/id/49290071

56 http://www.nbcmiami.com/news/Medicare-Fraud-Arrests-More-Than-30-Busted-in-Miami-in-Nationwide-Takedown-172692771.html

57 http://capsules.kaiserhealthnews.org/index.php/2012/10/houston-hit-hard-in-latest-medicare-fraud-bust/58 http://crimeblog.dallasnews.com/2012/10/federal-officials-announce-another-dallas-area-medicare-fraud-bust.html/

26

attorneys indicating that this reinforced his concerns that CIGNA was not looking for certain

types of fraud as it relates to increasing risk.

118. An emergency conference call between CIGNA’s attorneys and Mr. Bonewitz

was held. CIGNA Assistant Chief Counsel exclaimed to Mr. Bonewitz, “You were not told to

do this,” referencing uncovering providers committing fraud. This statement reflected an intent

to conceal versus an intent to investigate the concerns.

E. XVII. PLAINTIFF’S DATA ACCESS REMOVED, SUSPENDED, TERMINATED

119. The next day, a Friday, at the demand of the owners, CIGNA’s attorney removed

Plaintiff’s data access. The following Monday he was suspended and then later terminated.

120. After being terminated from employment, Mr. Bonewitz uncovered a pattern

of highly unethical behavior that had occurred or was occurring within CIGNA, buried in

‘the web’; including fines related to not properly responding to disputes, charges, and

other felonious activity.

121.

XVIII.F. WRONGFUL TERMINATION DEPOSITION FIDUCIARY BREACH

122. Mr. Bonewitz filed a wrongful termination Complaint against his former

employer, HealthSpring/New Quest regarding concerns of fraud. Mr. Bonewitz was paid through

New Quest even though he was a CIGNA employee receiving CIGNA benefits.

123. During the Discovery process Mr. Bonewitz turned over a dossier of research and

evidence to CIGNA’s Representation which included over 100 pages of information regarding

how CIGNA was committing fraud.

27

124. During Mr. Bonewitz’s deposition in this matter, CIGNA/New Quest’s

representation made several extremely disturbing public comments. These comments

demonstrated CIGNA’s propensity to conceal and disregard its moral and fiduciary obligations

to members.

125. Comments made by CIGNA/New Quest’s representation included, “You can’t

prove fraud can you?!” Additionally, CIGNA/New Quest’s representation indicated through

comments during public testimony that Mr. Bonewitz was simply pursuing legal Qui Tam action

against CIGNA/New Quest in order to make money. This indicated that CIGNA’s representation

was highly aware of the evidence, the Qui Tam documents and concerns of fraud that Mr.

Bonewitz had been forced to turn over to CIGNA’s representation in the dossier, through

discovery. Both CIGNA and their representation had an opportunity to address, dispute or refute

the fraud concerns and evidence contained within those documents, but chose not to. Instead

CIGNA/New Quest’s representation chose to focus its attention on what they represented as Mr.

Bonewitz’s self-interest for wanting to pursue Qui Tam action against CIGNA.

126. CIGNA/New Quest’s representation also appeared to have taken highly unethical

steps in order to put these Qui Tam documents, which contained important evidence, under seal.

These documents outlined how fraud was being committed by CIGNA/New Quest against its

HealthSpring Members.

127. The actions that occurred, in getting evidence put under seal, included deceiving

and pressurizing Mr. Bonewitz into signing a non-disclosure statement just seconds before the

deposition was to begin. Mr. Bonewitz was tricked into believing that the intent of the non-

disclosure was to conceal private patient data that CIGNA wanted to discuss related to Zotec

Partners. The non-disclosure document involving Zotec Partners could have been presented at

any other point in time. Missing the deposition implied serious repercussions.

28

128. Forcing Mr. Bonewitz to sign a non-disclosure document with Zotec Partners

gave CIGNA’s representation the ability to conceal all documents related to fraud as well as the

collusion between CIGNA and Zotec Partners that had been outlined within the documents. This

is a serious ethical violation for a public company such as CIGNA.

129. While keeping fraud under seal for a government investigation is a good practice

if conducted by the Plaintiff, it is bad for public interest when it is done by the hands of the

accused perpetrator.

130. A dispute regarding the unethical tactics, validity and the nature of the non-

disclosure was sent to CIGNA’s and Zotec Partners’ representation. No response was received

addressing the concerns.

131. The business models, compliance and owners of HealthSpring and CIGNA are the

same.

132. Mr Bonewitz believes, as a result of CIGNA’s evasiveness, that the same type of

fraud that he alleged was occurring against Health Spring members is also occurring against

CIGNA’s members.CIGNA’s members.

XIV. ZOTEC PARTNERS MEDICAL BILLING PRACTICES

A. PLAINTIFF HIRED AS BUSINESS INTELLIGENCE ANALYST

133. 95. Mr. Bonewitz began his employment with Zotec Partners on or about

August 1, 2011 as a Business Intelligence analyst and data warehouse developer. Plaintiff is

highly qualified to work within his particular specialty, the design and implementation of data

warehouse systems, the type of which the company utilizes for billing and managing patient

medical records.

29

134.

135. 96. Plaintiff through his specialized training and prior business background is

qualified to detect instances in the manner in which client is storing data that could result in data

being misused, misapplied or subject to fraud. Further, Plaintiff is qualified to determine if

problems could arise that would lead to allegations of fraudulent activity and the need of

companies to not violate federal law in the normal course of their business.

136.

137. 96. Through the normal course of his assigned work as an employee for

Company, Plaintiff determined that many of the processes and, in fact, a good portion of the

Company’s business model were based on a scheme to commit fraud.

138.

139. 97. Plaintiff, seeking to learn more about the Company’s business model, asked

questions in different departments to discover how the Company operated. Plaintiff was

informed that the Company made money from billing on behalf of its clients to private health

insurance companies including CIGNA. Plaintiff was told, and the same information was

presented in Company website marketing, that CIGNA seeks to generate the most money

possible for its clients.

B. IMPROPER CODING PRACTICES

140. 98. Plaintiff learned through colleagues that medical coders in India and

inexperienced interns were coding CIGNA medical bills in isolation and without physician

supervision or involvement. Plaintiff believed that this method of coding prevented coders from

getting valuable feedback from a physician in order to code accurately.

30

141. 99. Mr. Bonewitz was concerned, based on conversations overheard and

personal observation, that interns were deliberately being given specific types of complex claims

to code, that are prone to mistakes. Such complex coding by isolated inexperienced interns could

lead to repeated false claims and unnecessary charges to CIGNA or to the member as a result of

a denied claim. Using interns to consistently code without physician supervision could be

designed to shield the owners from fraud implications.

142. Mr. Bonewitz was also concerned, based on his internal experiences and

knowledge, that isolated medical coders working in India without interaction with physicians

may be getting directed to code CIGNA medical bills in a way that Zotec Partners wants.

143. Mr. Bonewitz believed that the inexperienced intern coders and the medical

coders in India lacked the knowledge and ability to speak up regarding fraud or false claims.

More importantly, Plaintiff believed these coders lacked the whistleblower protections that

would afford them the ability to speak up.

144. Mr. Bonewitz believed that employing inexperienced interns and outsourced

coders who lacked protections, was designed to strategically and systematically prevent false

claims from being reported.

B. PREVENTING DISPUTES THROUGH PHONE PRACTICES

145. Plaintiff’s final project at Zotec Partners involved creating logic for a new IVR

automated phone system. During this development Plaintiff needed to learn about the current

phone and billing system software, the Electronic Billing Center. He did this by watching live

training of a phone representative and through communicating with other IT developers.

31

146. During this observation period Mr. Bonewitz noticed that phone representatives

were not taking notes in the billing system as it related to billing disputes and they were not

being supervised to do so.

C. LACK OF PROPER LOGGING AND DISPUTE TRACKING

147. Mr. Bonewitz also communicated with IT resources regarding the Electronic

Billing Center and learned that logging was not being used to track or handle CIGNA member

disputes. There appeared to be no processes being used to verify the accuracy of the coding of

the bill as a result of a member dispute. Mr. Bonewitz found that there were no tracking

processes that allowed for communication between the coder in India and the physician in

another remote location to help resolve billing discrepancies. In other words, if a CIGNA

Member complained of a bill a phone representative did not have the means to appropriately

handle CIGNA billing disputes for the consumer.

148. Mr. Bonewitz, during the course of development of the automated phone system,

listened to recorded conversations between the phone representative and the CIGNA member.

He observed that none of the phone calls he listened to had any notes associated with them. In

fact many calls involving disputes were labeled “Canceled.” Many other calls were simply

designated with one note such as “Information,” “Canceled” or “Dispute” with no other

information provided. Mr. Bonewitz noticed a lack of notes in the system regarding phone calls

and verified this with the phone system trainer. Mr. Bonewitz also noted that a common

consumer complaint in several of the calls he heard was a lack of diagnosis codes in their bills.

D. CONCEALING DIAGNOSIS CODES FROM BILLS TO PREVENT

DISPUTES

32

149. Mr. Bonewitz was concerned that concealing the diagnosis code in the bill was

another means of preventing a CIGNA member from effectively disputing a medical bill.

150. Plaintiff grew increasingly concerned that the combination of billing methods

designed to prevent disputes combined with its medical coding processes were part of a Zotec

Partners’ scheme intended to systematically defraud CIGNA members. It appeared that Zotec

Partners’ intent was to make challenging a bill so difficult that CIGNA members would give up

pursuing disputes so that either CIGNA or the member would bear the expense.

151. Mr. Bonewitz became concerned that, based on the code he was converting for

the new automated phone system, the true intent behind the system was to make it even more

difficult for CIGNA members to dispute false claims.

152. Mr. Bonewitz learned from co-workers that there had been multiple failed

attempts to deploy the IVR automated phone system and that the system had been temporarily

disabled due to a high level of consumer complaints to Zotec Partners’ clients.

153. Mr. Bonewitz feared that the intent of the new automated phone system logic was

not to provide the best service possible, but to handle calls in a way to reduce the level of

complaints getting back to clients while also preventing disputes.

E. USING AUTOMATION TO FURTHER PREVENT DISPUTES AND

CONCEAL FRAUD

154. Mr. Bonewitz also learned from IT colleagues that a new automated medical

coding system was being tested, that had been developed externally. This automated system

would purportedly replace medical coders in order to save money. Mr. Bonewitz was concerned

this new automated coding system would further shield how coding was being performed. Mr.

Bonewitz was concerned about the timing of the implementation of the automated system as it

33

was occurring while Zotec Partners was facing litigation from a physician client regarding

accusations of violating HIPAA for outsourcing medical coding overseas. Mr. Bonewitz was

also concerned that the intent of this new coding system was to defraud CIGNA members

(among others) with minimal human interaction.

155. Based on the combined business practices of outsourcing, using inexperienced

intern coders and the lack of appropriate systems for handling disputes, it appeared Zotec

Partners’ intent was not to code for accuracy but to code claims in a way that would result in the

highest possible revenue for their clients. By coding claims to meet the acceptance policies of

CIGNA as opposed to the physician’s raw data, such a process could result in a large volume of

false claims and could artificially increase member risk.

F. CONCEALING ACCOUNTABILITY AND FRAUD BY NOT DOCUMENTING

BUSINESS PROCESSES

156. Plaintiff noticed that important business processes, instead of being formally

written, were being conveyed verbally by the owner to an inexperienced entry level business

analyst who had been with the organization for just two months. This analyst, who had minimal

coding experience, was then instructed to translate the business information to code. Such a

process could be used to obfuscate fraud and shield accountability. Such practices drew

Plaintiff’s attention because of the size of the organization.

157. Plaintiff believed that the true purpose behind automation of processes was not to

reduce work force in order to save costs, but to reduce exposure related to fraud.

G. PSYCOLOGICAL TACTICS AND HIRING METHODS TO PREVENT

FRAUD

34

158. Additionally, Plaintiff believed company was using psychological tactics

including intimidation, isolation, high workload and stress in certain departments to prevent

employees from ‘seeing’ fraud and/or from having the ability to communicate fraud concerns.

Plaintiff believed that Zotec Partners was intentionally hiring unpaid medical coding interns

(who are unprotected from wrongful termination laws) and underqualified employees in certain

departments; then systematically terminating certain employees with offered severances, while

disputing unemployment pay in order to prevent lawsuits for fraud. Conversely, Zotec Partners

also rewarded employees with an annual casino trip while handing a few hundred dollars out to

each employee to go spend. Such a tactic can make it very easy for lower income workers to

look past company transgressions.

E. PLAINTIFF TERMINATED AFTER REPORTING CONCERNS

159. During an October 14 meeting, Plaintiff discussed his concerns with his boss, the

manager of the Business Intelligence department, that many aspects of the company were

fraudulent.

160. The following Monday his manager left on a business trip to Las Vegas while Mr.

Bonewitz worked on the IVR Phone system automation project and another project.

161. On October 20th, the day prior to his manager’s return from Las Vegas, Mr.

Bonewitz sent his manager a letter regarding his concerns with the IVR phone automation

project as it related to preventing disputes. He also included a separate letter regarding

management’s lack of writing and tracking requirements for business process.

162. Plaintiff was wrongfully terminated by Company on October 21, 2011.

163. Below are representative comments from the job and career website Glassdoor

that indicates the attitude of employees. (See exhibit X for full comments)

35

Former employee: Another Zotec statistic…laid off former MMP office: “Wish I could think of something positive to say here but I have nothing…The communication that we did have was a bunch of empty promises.”

Current employee. Sad-just very sad: “Mean Spirited Leadership- Do NOT Value their people, unless you are part of their good ole boys click…They do not even treat many of their clients with respect or deliver on service promises.”

Former employee. Recently laid off due to Zotec purchase of Cbiz: “This company outsources to India giving away American jobs, laying off their own for the almighty dollar…The micromanagement going on and secrets behind closed doors is the first signs of an office in trouble.”

Current employee. Disorganized with no clear direction: “Streamlining systems seems to be the main goal, without any thought to personnel or clients.”

Current employee. Since Zotec bought out MMP, things have gone downhill: “There is little to no communication from upper management…We have fewer employees but are still expected to get the work done.”

Former employee. I would not advise anyone to accept a job offer from this company: “No matter how much you get done, ridiculous deadlines will be put in front of you weekly. Friday at 1pm you will be told “all of these need to be done before you leave today.” This place was a nightmare…While I was there the support developers were treated even worse than we were. They were fired so fast it didn’t even make sense to us why they bothered to hire them.”

Former employee. (CAN’T READ HEADLINE): “This is the most negative, demoralizing demanding company I have ever encountered. The management is done by intimidating and demaning staff – it is not unusual to be screamed at by the CEO or his staff.”

Former employee. Stay away!! Burn and churn company: “Extremely bad reputation amonf the healthcare community as having a high turn over rate, and burning people out. You are expected to speak with no one, sit at your desk and work 8 hours straight!”

Current employee. This company values software not people/employees: “Some managers do not aloow talking between co workers. No cell phones allowed. Expect to account for every minute you are on the clock. Cublicle farms. Oppressive. Don’t expect any personal space or privacy.”

36

164. Subsequent to Plaintiff’s termination from both Zotec Partners and CIGNA,

Plaintiff brought his concerns to Zotec Partners representation that CIGNA and Zotec Partners

were both being complicit to fraudulent practices for mutual benefit. This was outlined in a 50+

page two-part document which . discussed all relevant facts outlined in this lawsuit.

165. The document explained how ZotecPartners was able to commit systematic fraud

and why CIGNA was complicity allowing it through a process of collusion.

166. Mr. Bonewitz also indicated to Zotec Partners representation the psychological

tactics that Zotec was using against unpaid interns and other employees, prior to the comments

made on Glassdoor.

167. Mr. Bonewitz provided Zotec Partners an opportunity to address, refute or dispute

the concerns of fraud presented in the document and Zotec Partners neglected to do so

XVI. DAMAGES TO PLAINTIFF

168. Consumer paid an inflated premium as a result of CIGNA’s negligence and

fraudulent practices.

169. This negligence and fraud includes using incentives to increase volume,

exploiting the outdated ICD-9 diagnosis tool which is used throughout CIGNA’s provider

network and strategically accepting millions of claims for treatment such as labs, imaging (e.g.

x-rays) and pharmaceuticals based on the diagnosis code provided in order to manipulate risk.

Such a process has resulted in a grossly inaccurate picture of the true health conditions of the

members.

170. Zotec Partners’ manipulative coding process on millions of claims has resulted in

artificially increasing the risk of CIGNA members and has been highly influential in inflating

37

premium prices for ALL CIGNA members. As a result of Zotec Partners’ practices, Plaintiff

paid a higher premium rate then he would have had they been coding following ‘best practices’

and not coding specifically to have certain claims accepted. Zotec Partners, therefore, damaged

Plaintiff by causing him to pay CIGNA premiums at an inflated rate.

171. Zotec Partners coding processes include coding in a way that CIGNA wants, for

certain imaging claims (such as chest X-rays) while preventing disputes, in order to get paid by

the health insurance company. Zotec Partners is also coding claims that get passed on to the

CIGNA member, while preventing disputes which prevents members from getting the full value

from their insurance.

172. The nature of the fraud specifically against Plaintiff, by CIGNA, included

leveraging faulty lab tests, exploiting weakness in the outdated ICD-9 coding tool and

strategically accepting certain diagnosis codes for a specific procedure (Low-T treatment) in

order to artificially increase risk. This process would cause plaintiff’s true health to be negatively

and inaccurately misstated resulting in irreparable harm and unknown future damages.

173. CIGNA’s fraud, deception, negligence and other unethical business practices

intended to guide treatment for CIGNA’s own self-interest created a monumental breach of trust

and severely eroded the value of health care that it offers and therefore the premium’s intrinsic

value or true worth to Consumer.

174. Because CIGNA is grossly misrepresenting its ethical standards, its premium

value is severely overstated. Consumer purchased the health insurance based on an inherent trust

that the healthcare CIGNA was providing was in his family’s best interest. However, CIGNA has

on numerous occasions breached this trust and violated the promises and representations that it

made. As a result consumer paid more than he should have because CIGNA misrepresented its

services.

38

175. Further, had Plaintiff known the full scope of CIGNA’s highly unethical and

unscrupulous behavior he would never have purchased CIGNA insurance for himself and his two

daughters no matter what the premium. Such behavior includes fines and previous Complaints

against it, violation issues raised by members of the U.S. Senate (lab pull through arrangements),

incentives used to increase volume of certain procedures, a scheme to artificially increase risk,

violation of employee rights to conceal fraud concerns, spin used by publicity officers to control

perception, and measures that can be used to bury negative publicity.

176. CIGNA’s breach of trust caused emotional damage to Consumer by creating

doubt and concern regarding the practices of his provider network and the true nature for which

the labs, imaging and pharmaceuticals are being referred. Ultimately, it forced him to leave the

provider network from which he received his primary care.

177. CIGNA and Zotec Partners denied Plaintiff the ability to focus on his proprietary

time-sensitive development project (a network of hundreds of social web sites and commerce

trade sites) during a very pivotal time; which has caused delay to market causing and substantial

loss of income and net worth. These damages were foreseeable and contemplated by CIGNA

and Zotec Partners. CIGNA as they became privy to Plaintiff’shis substial investment in his

proprietary development workin the propr develphrough the rry and depositios. Zotec Partner’s

was fully aware for much longer and turned over email evidence to CIGNA/HealthSpring which

verifies this. Therefore these damages come as no surprise to both CIGNA and Zotec Partners.

XVII.

CAUSES OF ACTIONXV. DAMAGES

39

Consumer paid an inflated premium as a result of CIGNA’s negligence and fraudulent practices.

This includes the continued use of an outdated ICD-9 diagnosis tool that CIGNA utilizes

throughout its provider network, which inaccurately reflects conditions and therefore risk

compared to the capabilities of ICD-10. Strategically accepting claims based on their diagnosis

so that risk goes up would cause Plaintiff to pay an inflated premium as result of the diagnosis

code being manipulated in order for claim to be paid (accepted).

Zotec Partners has been coding in a way that CIGNA wants, for certain imaging claims (such as

chest X-rays) while preventing disputes, in order to get paid by the health insurance company.

This manipulative process has resulted in artificially increasing the risk of CIGNA members and

has been highly influential in inflating premium prices for ALL CIGNA members. As a result of

Zotec Partners’ practices, Plaintiff paid a higher premium rate then he would have had they been

coding following ‘best practices’ and not coding specifically to have certain claims accepted.

Zotec Partners, therefore, damaged Plaintiff by causing him to pay CIGNA premiums at an

inflated rate.

The nature of the fraud specifically against Plaintiff, by CIGNA, included leveraging faulty lab

tests, exploiting weakness in the outdated ICD-9 coding tool and strategically accepting certain

diagnosis codes for a specific procedure (Low-T treatment) in order to artificially increase risk.

This process would cause plaintiff’s true health to be negatively and inaccurately misstated

resulting in irreparable harm and unknown future damages.

CIGNA’s fraud, deception, negligence and other unethical business practices intended to guide

treatment for CIGNA’s own self-interest created a monumental breach of trust and severely

eroded the value of health care that it offers and therefore the premium’s intrinsic value or true

worth to Consumer.

40

Because CIGNA is grossly misrepresenting its ethical standards, its premium value is severely

overstated. Consumer purchased the health insurance based on an inherent trust that the

healthcare CIGNA was providing was in his family’s best interest. However, CIGNA has on

numerous occasions breached this trust and violated the promises and representations that it

made. As a result consumer paid more than he should have because CIGNA misrepresented its

services.

Further, had Plaintiff known the full scope of CIGNA’s highly unethical and unscrupulous

behavior he would never have purchased CIGNA insurance for himself and his two daughters no

matter what the premium. Such behavior includes fines and previous Complaints against it,

violation issues raised by members of the U.S. Senate (lab pull through arrangements), incentives

used to increase volume of certain procedures, a scheme to artificially increase risk, violation of

employee rights to conceal fraud concerns, spin used by publicity officers to control perception,

and measures that can be used to bury negative publicity.

CIGNA’s breach of trust caused emotional damage to Consumer by creating doubt and concern

regarding the practices of his provider network and the true nature for which the labs, imaging

and pharmaceuticals are being referred. Ultimately, it forced him to leave the provider network

from which he received his primary care.

COUNT I

CONSUMER FRAUD

178. Plaintiff incorporates the foregoing allegations as if fully set forth herein.

179. As described herein, CIGNA has engaged in unlawful, deceptive, and unfair

conduct that is immoral, unscrupulous, and caused substantial injury to Plaintiff.

41

180. Through its online marketing materials and advertisements CIGNA represented to

Plaintiff that it would, inter alia, provide healthcare in an ethical way and could be entrusted with

looking out for the best interests of Plaintiff.

181. CIGNA’s promises and representations made on its websites and in marketing

with respect to caring about people, demonstrating courage, acting with integrity, commitment to

excellence, helping to keep people well, and investigating fraud for Plaintiff’s best interests were

in fact, false.

182. CIGNA has failed to care about people and has proven that through the numerous

charges and fines against it including, among other things, wrongfully denying mental health

treatment claims59. Additionally, CIGNA has failed to respond to customer concerns online and

in popular forums when it has the capability and could easily do so. CIGNA has also failed to

care about people by failing to oversee how its partner American Specialty Health is treating its

members and ensuring that its partner is addressing complaints and concerns in forums and on

websites.

183. CIGNA has failed to act with courage when the need has arisen. Instead of

assisting on concerns of fraud, fellow employees, including the HR Manager, responded with

complacency by allowing the Plaintiff’s data access to be removed and then allowed Plaintiff to

be suspended despite an ongoing investigation. Additionally, CIGNA representatives on

repeated occasions acted with severe intimidation against Plaintiff in order to bring shame and

fear so that he would be discouraged from pursuing a duty that is morally right. When tested,

CIGNA employees and representatives failed to act with courage and assist Plaintiff when he

was trying to look out for the best interests of the members. CIGNA has failed to act with

integrity on numerous occasions. Instead of acting with truthfulness and honesty, CIGNA, 59 http://www.ag.ny.gov/press-release/ag-schneiderman-announces-settlement-health-care-insurer-wrongfully-denying-mental

42

among other things, has chosen to be evasive in regards to how it has handled reported concerns

of fraud and challenges against the organization.

184. CIGNA has failed in its promise to help keep people well. It has contradicted

expert opinion, on, among other things, how it is accepting testosterone treatment claims for

people that don’t medically need it and where it could be medically harmful. Additionally,

CIGNA’s wrongful denial of treatment60 for nutritional (eating) disorders could have put the

health of those patients in serious jeopardy.

185. CIGNA has failed in its commitment to excellence by, among other things, not

upgrading to ICD-10 in a timely manner and by failing to evangelize change and make change

happen within its provider network and/or within the private health care industry with regards to

upgrading to ICD-10.

186. CIGNA has failed in its commitment to investigate fraud when it pertained to

Plaintiff’s best interests. CIGNA did not perform an adequate impartial fraud investigation when

put under the requirement to do so. CIGNA, when presented with concerns of fraud, as well as

documents and evidence, failed to respond in a transparent manner in order to look out for

Plaintiff’s best interests, despite the fact that he was an IT employee that deserved rightful

privilege to this information.

187. Thus CIGNA’s representations to Plaintiff were false and CIGNA knew they

were false.

188. CIGNA has made the false representations with the intention that Plaintiff would

rely on them in joining CIGNA and to command a higher premium rate. It did so while knowing

that Consumer is less likely to do business with or pay a high premium to a company that acts

60 http://www.ag.ny.gov/press-release/ag-schneiderman-announces-settlement-health-care-insurer-wrongfully-denying-mental

43

unethically, does not care about people, act with integrity, properly investigate fraud, help to

keep people well, look out for its member’s best interests or act with courage.

189. Because CIGNA concealed proprietary information regarding its true business

policies, practices and procedures, CIGNA deceived Consumer and therefore likely members

who have no other resource for assessing CIGNA’s services.

190. Had CIGNA disclosed its true practices, Plaintiff would have paid substantially

less for CIGNA’s premiums or would not have paid at all (i.e., the value of CIGNA’s premiums

are worth substantially less when internal fraud investigations are being covertly handled,

numerous unethical charges and violations have occurred, not providing excellence). Because

Plaintiff paid in part for CIGNA to act ethically, with integrity, properly investigate fraud in the

best interests of Plaintiff, demonstrate courage, help to keep him well, and act with a

commitment to excellence Plaintiff did not receive the services for which he paid.

191. CIGNA’s deceptive conduct also caused Plaintiff monetary damages because had

he known that the testosterone treatment was not medically needed and could in fact be harmful

to both his physical health and his risk assessment, he would not have made co-payments and

invested in the treatment but would have sought treatment for his ‘condition’ in another way.

192. Further, CIGNA’s deceptive practices intended to artificially increase risk through

; incentivizing providers, strategically accepting claims with certain diagnosis codes, leveraging

weaknesses in the ICD-9 diagnosis tool and lack of correction to diagnosis based on fraudulent

(false) claims; has caused the premium to be artificially high.

193. CIGNA’s deceitful practice to artificially increase risk caused harm to Consumer

by causing him to pay falsely inflated premium rates.

194. Zotec Partners’ deceptive practices of manipulating diagnosis codes to meet

CIGNA’s acceptance policies while preventing disputes has led to artificially increasing member

44

risk. As a result, Zotec Partners caused damage to plaintiff. By artificially influencing risk and

therefore premiums, Zotec Partners caused Plaintiff to pay his premium based on an inflated rate

195. CIGNA’s and Zotec Partners’ conduct also constitutes unfair conduct because it

caused substantial injury to Plaintiff that was not offset by countervailing benefits to Consumer

or competition and was not reasonably avoidable by Consumer.

196. The harm suffered by Plaintiff was not reasonably foreseeable because he lacked

firsthand knowledge of CIGNA’s business practices given CIGNA’s false public representations

regarding the same.

197. CIGNA’s deceptive, unlawful, and unfair conduct occurred in the course of

Consumer’s purchasing health insurance premiums and therefore occurred in the course of

conduct involving trade and commerce.

198. In sum, CIGNA’s deceptive, unlawful, and unfair conduct caused Plaintiff

monetary damages. Plaintiff would have paid substantially less for CIGNA’s services or would

have not paid at all had he known that CIGNA was misrepresenting its services and also inflating

the premiums based on artificially risk assessments. Likewise Plaintiff would not have paid for

testosterone treatment co-pays and had invested in treatment but for CIGNA’s unlawful,

deceptive and unfair conduct.

199. Accordingly, Plaintiff seeks an order (i) preliminarily and permanently enjoining

CIGNA from continuing to engage in unfair and fraudulent conduct, (ii) requiring CIGNA make

full restitution of all funds wrongfully obtained, and (iii) awarding punitive damages, costs, and

reasonable attorney’s fees to Plaintiff.

COUNT II

WIRE FRAUD

45

(29 USC 1105)

200. Plaintiff incorporates the foregoing allegations as if fully set forth herein.

201. Through its interstate and foreign marketing advertisements, CIGNA represented

to Plaintiff that it would, inter alia, provide healthcare in an ethical way and could be entrusted

with looking out for the best interests of Plaintiff.

202. CIGNA’s promises and representations made on its websites and in marketing

with respect to caring about people, demonstrating courage, acting with integrity, commitment to

excellence, helping to keep people well, and investigating fraud for Plaintiff’s best interests were

in fact, false.

203. CIGNA has failed to care about people and has proven that through the numerous

charges and fines against it including, among other things, wrongfully denying mental health

treatment claims61. Additionally, CIGNA has failed to publically respond to customer concerns

online and in popular forums when it has the capability and could easily do so. CIGNA has also

failed to care about people by failing to oversee how its partner, American Specialty Health, is

treating its members and ensuring that its partner is addressing complaints and concerns in

forums and on websites.

204. CIGNA has failed to act with courage when the need has arisen. Instead of

assisting on concerns of fraud, fellow employees, including the HR Manager, responded with

complacency by allowing the Plaintiff’s data access to be removed and then allowed Plaintiff to

be suspended despite an ongoing investigation. Additionally, CIGNA representatives on

repeated occasions acted with severe intimidation against Plaintiff in order to bring shame and

fear so that he would be discouraged from pursuing a duty that is morally right. When tested,

61 http://www.ag.ny.gov/press-release/ag-schneiderman-announces-settlement-health-care-insurer-wrongfully-denying-mental

46

CIGNA employees and representatives failed to act with courage and assist Plaintiff when he

was trying to look out for the best interests of the members.

205. CIGNA has failed to act with integrity on numerous occasions. Instead of acting

with truthfulness and honesty, CIGNA among other things, has chosen to be evasive in regards

to how it has handled reported concerns of fraud and challenges against the organization.

206. CIGNA has failed in its promise to help keep people well. It has contradicted

expert opinion, on, among other things, how it is accepting testosterone treatment claims for

people that don’t medically need it and where it could be medically harmful. Additionally,

CIGNA’s wrongful denial of treatment62 for nutritional (eating) disorders could have put the

health of those patients in serious jeopardy.

207. CIGNA has failed in its commitment to excellence by, among other things, not

upgrading to ICD-10 in a timely manner and by failing to evangelize change and make change

happen within its provider network and/or within the private health care industry with regards to

upgrading to ICD-10.

208. CIGNA has failed in its representations of a commitment to investigate fraud

when it pertained to Plaintiff’s best interests. CIGNA did not perform an adequate impartial

fraud investigation when put under the requirement to do so. CIGNA, when presented with

concerns of fraud, as well as documents and evidence, failed to publically respond in a

transparent manner in order to indicate that it was looking out for Plaintiff’s best interests,

despite the fact that Plaintiff was an IT employee that deserved rightful privilege to this

information.

209. Thus CIGNA’s representations to Plaintiff were false and CIGNA knew they

were false.62 http://www.ag.ny.gov/press-release/ag-schneiderman-announces-settlement-health-care-insurer-wrongfully-denying-mental

47

210. Knowing that Consumer is less likely to do business with or pay a high premium

to a company that acts unethically, does not care about people, act with integrity, properly

investigate fraud, help to keep people well, look out for its member’s best interests or act with

courage; CIGNA has made the false representations with the intention that Plaintiff would rely

on them in joining CIGNA and to command a higher premium rate.

211. Because CIGNA concealed proprietary information regarding its true business

policies, practices and procedures, CIGNA deceived Consumer and therefore likely members

who have no other resource for assessing CIGNA’s services.

212. Had CIGNA disclosed its true practices, Plaintiff would have paid substantially

less for CIGNA’s premiums or would not have paid at all (i.e., the value of CIGNA’s premiums

are worth substantially less when internal fraud investigations are being covertly handled,

numerous unethical charges and violations have occurred, not providing excellence). Because

Plaintiff paid in part for CIGNA to act ethically, with integrity, properly investigate fraud in the

best interests of Plaintiff, demonstrate courage, help to keep him well, and act with a

commitment to excellence Plaintiff did not receive the services for which he paid.

213. CIGNA’s deceptive conduct also caused Plaintiff monetary damages because had

he known that the testosterone treatment was not medically needed and could in fact be harmful

to both his physical health and his risk assessment, he would not have made co-payments and

invested in the treatment but would have sought treatment for his ‘condition’ in another way.

214. Further, CIGNA’s deceptive practices intended to artificially increase risk through

incentivizing providers, strategically accepting claims with certain diagnosis codes, leveraging

weaknesses in the ICD-9 diagnosis tool and lack of correction to diagnosis based on fraudulent

(false) claims has caused the premium to be artificially high.

48

215. Zotec Partners’ deceptive practices of manipulating diagnosis codes to meet

CIGNA’s acceptance policies while preventing disputes has led to artificially increasing member

risk. As a result, Zotec Partners caused damage to plaintiff. By artificially influencing risk and

therefore premiums, Zotec Partners caused Plaintiff to pay his premium based on an inflated

rated.

216. CIGNA’s deceitful practice to artificially increase risk caused harm to Consumer

by causing him to pay falsely inflated premium rates.

217. CIGNA’s deceptive practices constitute wire fraud because its representations

occurred in foreign lands and interstate; also wire transactions made by the Plaintiff occurred

predominantly out of state.

218. Zotec Partners fraud constitutes wire fraud because wire transactions occur out of

state.

219. The harm suffered by Plaintiff was not reasonably foreseeable because he lacked

firsthand knowledge of CIGNA’s business practices given CIGNA’s false public representations

regarding the same.

220. In sum, CIGNA’s deceptive, unlawful, and unfair conduct caused Plaintiff

monetary damages. Plaintiff would have paid substantially less for CIGNA’s services or would

have not paid at all had he known that CIGNA was misrepresenting its services and also inflating

the premiums based on artificial risk assessments. Likewise Plaintiff would not have paid for

testosterone treatment co-pays and had invested in treatment but for CIGNA’s unlawful,

deceptive and unfair conduct.

221. Accordingly, Plaintiff seeks an order (i) preliminarily and permanently enjoining

CIGNA from continuing to engage in unfair and fraudulent conduct, (ii) requiring CIGNA make

49

full restitution of all funds wrongfully obtained, and (iii) awarding punitive damages, costs, and

reasonable attorney’s fees to Plaintiff.

222.

COUNT III

FRAUD IN THE INDUCEMENT

223. Plaintiff incorporates the foregoing allegations as if fully set forth herein.

224. CIGNA misrepresented and/or failed to disclose material provisions related to the

sale of its health insurance membership.

225. Through the misrepresentation and omissions detailed herein, CIGNA wrongfully

induced Plaintiff to purchase its services. These representations include statements on

Defendant’s websites indicating that CIGNA cares about people, demonstrates courage, acts with

integrity, has a commitment to excellence, helps to keep people well, and will investigate fraud

for Plaintiff’s best interests.

226. In addition, through reverse SEO techniques involving the creation of numerous

social sites, web pages, and back links CIGNA has suppressed pertinent derogatory information

including fines, charges, consumer complaints, and lawsuits that would have been relevant to

Plaintiff in making a purchase decision.

227. Defendant knew or should have known that its misstatements and omissions

regarding the sale of its services were misleading to Plaintiff.

228. Defendant intended that Consumer would rely upon its misstatements and

omissions regarding the sale of its services.

50

229. In deceiving Plaintiff regarding the full terms of the sale of its services, CIGNA

has engaged in fraudulent practices designed to induce Consumer to sign up and use its services.

230. Defendant participated in a fraudulent scheme to defraud consumersConsumer.

Specifically, Defendant made numerous false statements and broke numerous promises,

including but not limited to caring about people, demonstrating courage, acting with integrity, a

commitment to excellence, helping to keep people well, and investigating fraud for Plaintiff’s

best interests. Defendant perpetrated the fraudulent scheme through faulty faulty operations

occurring organization wide including;; Compliance, HR, attorneys and customer service.. In

addition In addition, CIGNA perpetrated the fraud by suppressing important newsworthy

information from the consumer through reverse SEO techniques that prevented Plaintiff from

seeing a consistent pattern of unethical business practices. Had plaintiff known that CIGNA

Compliance and CIGNA’s representation would completely fail to properly investigate his

concerns, despite company placards asking people to come forward, he never would have

purchased the insurance. Finally, plaintiff never would have purchased CIGNA insurance had he

known that CIGNA’s representation would completely dismiss his knowledge and expertise

regarding concerns of fraud, during a deposition, after implying that only employees specially

trained in uncovering fraud are qualified to report concerns.

231.

232. As a result of CIGNA’s violations of wrongful conduct alleged herein, Plaintiff

suffered actual harm. Plaintiff suffered economic injury and other damages, including the

amount of the difference between the price Plaintiff paid for CIGNA’s services as promised and

the diminished value of its services. Further Plaintiff suffered damages in the form of paying an

inflated premium based off of artificially increased risk as a result of false claims.

233. Accordingly, Plaintiff seeks an order (i) preliminarily and permanently enjoining

51

CIGNA from continuing to engage in unfair and fraudulent conduct, (ii) requiring CIGNA to pay

damages and make full restitution of all funds wrongfully obtained, and (iii) award punitive

damages to Plaintiff plus costs.

COUNT IV

NEGLIGENCE

234. Plaintiff incorporates the foregoing allegations as if fully set forth herein.

235. CIGNA had a duty to look for false claims where it could artificially raise

member risk and cause premiums to rise. CIGNA’s duty arose from the legal and industry

standard to perform as a trusted expert in the industry because members cannot do this

themselves. CIGNA, with 200 years of knowledge and expertise, has far greater capability to

detect fraud or false claims than a consumer. In addition they have greater resources. Finally, it

is CIGNA’s duty because the members have no one else that will look out for them.

236. Zotec Partners had a duty to code in an ethical way following industry best

practices which include proper supervision and physician involvement and/or interaction. Zotec

Partners also had a duty to allow consumers to properly dispute false claims or false diagnosis

codes in order to prevent their risk from artificially increasing. Zotec Partners had a duty not to

deceive consumers by implying that they are the physician’s office or medical facility. Such

deception would likely mislead the consumer in terms of its trustworthiness. As a result Zotec

Partners has been instrumental in causing risk to artificially increasing risk and forcing CIGNA

premiums to artificially inflate.

237.

238. 66. CIGNA, by breaching a duty to investigate false claims, has failed

to protect and safeguard the value of the health care it provides to the member and to ensure that

52

the member is receiving reasonable care in an ethical manner; free from abusive, fraudulent,

unethical, false or unnecessary charges. As a result, CIGNA has compromised the value of

health care.

239. CIGNA, through its actions and/or omissions, also breached its duty to the_e

240. Plaintiff by failing to require industry-standard protocols that would help protect

the member from being wrongfully charged through the unethical practices of medical billing

companies. This lack of industry protocols and standards has caused member risk to artificially

increase while also forcing the member to absorb costs that potentially CIGNA should have

absorbed. Some of the concerns related to a lack of industry standards include: outsourcing

coding to India, non-transparent coding practices, lack of physician suervision and lack of

process handling for disputes through billing companies. As a result of failing to require and

enforce industry standards in the medical billing industry, CIGNA has compromised the value of

health care.

241. CIGNA, through its actions and/or omissions, unlawfully breached its duty to the

Plaintiff by allowing providers to receive incentives whereby breaching the trust the member has

in the value of the healthcare process, the provider network and the value of the insurance

premium.

242. CIGNA had a duty to ensure that Plaintiff was receiving healthcare that was

beneficial to his health and in safeguarding him from harm. Specifically they had a duty to

protect him from receiving testosterone treatments that likely contained faulty diagnosis and

could lead to harmful effects.

243. CIGNA had a duty to adjust risk and therefore premium rates as a result of false

claims and faulty diagnosis. The result of false diagnosis codes on risk and premium rates was

reasonably foreseeable.

53

244. CIGNA through active creation of social sites, web pages and international

websites has been suppressing negative information and content on search results resulting in

deceiving consumers and misrepresenting the ethics and integrity of the organization. It caused

Plaintiff to falsely trust CIGNA. This was reasonably foreseeable.

245. But for CIGNA’s breach of its duties and trust, Plaintiff’s value in his health care

premiums would not have been compromised.

246. As a result of CIGNA’s conduct, Plaintiff suffered economic injury and other

damages, including without limitation the amount of the difference between the price he paid for

CIGNA’s services as promised and the actual diminished value of its services. Plaintiff suffered

damages as a result making co-payments for testosterone treatments he otherwise would not

have. Further, Plaintiff has suffered unknown damages as a result of false claims and

misdiagnosis that misrepresent his true health condition.

247. Accordingly, Plaintiff seeks an order requiring CIGNA to pay damages in

amounts to be proven at trial plus costs of this suit.

COUNT V

BREACH OF FIDUCIARY DUTY

248. As guardian of the Plaintiff, CIGNA owed a fiduciary duty to Plaintiff to maintain

transparency of its actions including contractual agreements and diligently find fraud even if it

meant premiums would go down.

249. CIGNA breached its fiduciary duty to the Plaintiff by: (i) failing to protect

members and ensuring that the medical billing industry is using coding processes following best

practices and ensuring that members are able to effectively dispute claims with the medical

billing companies so that they are billed fairly (and premiums or risk don’t go up needlessly). (ii)

54

failing to upgrade its private provider network to ICD-10 despite the known benefits to the

member (iii) failing to disclose contract incentives that may exist with providers, provider

networks or partnerships that could affect how healthcare is provided and the types of procedures

or screenings that are recommended (iv) Failing to properly handle an internal fraud

investigations, based on concerns brought by an employee, in a transparent manner, reflecting

the best interests of the consumer. (v) Failing to properly address or respond to concerns of fraud

brought by an employee on multiple occasions that affects the premiums of all members. (vi)

Failing to track medical billing companies in order to make fraud detection more efficient.

250. As a result of CIGNA’s breaches, the Plaintiff has suffered actual harm. Plaintiff

suffered economic injury and other damages, including, without limitation, the amount of the

difference between the price the member paid for CIGNA’s insurance premiums (that had been

established artificially) and the diminished value reflecting premiums that were established as a

result of unethical and unscrupulous practices.

251. Accordingly, Plaintiff seeks an order (i) preliminarily and permanently enjoining

CIGNA from continuing to engage in unfair and fraudulent conduct, (ii) requiring CIGNA to

make full restitution of all funds wrongfully obtained, held or charged, and (ii) awarding punitive

damages, costs, and reasonable attorneys to Plaintiff.

COUNT VI

BREACH OF FIDUCIARY DUTY TO AN ERISA PLAN(29 USC 1105 )

252. As guardian of the Plaintiff, CIGNA owed a fiduciary duty to Plaintiff to maintain

transparency of its actions including contractual agreements and diligently find fraud even if it

meant premiums would go down.

55

253. CIGNA breached its fiduciary duty to the Plaintiff by: (i) knowingly failing to

protect members and ensuring that the medical billing industry is using coding processes

following best practices and ensuring that members are able to effectively dispute claims with

the medical billing companies so that they are billed fairly (and premiums or risk don’t go up

needlessly) (ii) knowingly failing to upgrade its private provider network to ICD-10 despite the

known benefits to the member; (iii) knowingly failing to disclose contract incentives that may

exist with providers, provider networks or partnerships that could affect how healthcare is

provided and the types of procedures or screenings that are recommended; (iv) Failing to handle

internal fraud investigations, based on concerns brought by an employee, in a transparent

manner, reflecting the best interests of the consumer. (v) Failing to properly address or respond

to concerns of fraud brought by an employee on multiple occasions that affects the premiums of

all members. (vi) Failing to track medical billing companies in order to make fraud detection

more efficient;.

254. CIGNA, when issues of a breach of fiduciary duty were brought to its attention

for the aforementioned concerns, did not make reasonable or legitimate attempts to remedy the

breach.

255. As a result of CIGNA’s breaches, the Plaintiff has suffered actual harm. Plaintiff

suffered economic injury and other damages, including, without limitation, the amount of the

difference between the price the member paid for CIGNA’s insurance premiums (that had been

established artificially) and the diminished value reflecting premiums that were established as a

result of unethical and unscrupulous practices.

256. Accordingly, Plaintiff seeks an order (i) preliminarily and permanently enjoining

56

CIGNA from continuing to engage in unfair and fraudulent conduct, (ii) requiring CIGNA to

make full restitution of all funds wrongfully obtained, held or charged, and (ii) awarding punitive

damages, costs, and reasonable attorneys to Plaintiff.

COUNT VII

BREACH OF CONTRACT

257. Plaintiff incorporates the foregoing allegations as if fully set forth herein.

258. Plaintiff entered into valid and enforceable agreements with CIGNA whereby

CIGNA promised to provide services to Plaintiff, and Plaintiff agreed to pay money for and use

such services.

259. As part of this agreement, CIGNA represented through its website advertising that

it would act with integrity, help to keep people well, care about people, have a commitment to

excellence, investigate fraud for Plaintiff’s best interests, and act with courage.

260. Based on CIGNA’s representations Consumer agreed to sign up for CIGNA’s

health insurance and use its services.

261. CIGNA breached its contract with Plaintiff by failing on several of the promises it

had made. CIGNA failed to disclose that it had already breached its promises on numerous

occasions and/or was currently breaching the promise:

BREACH OF PROMISES

262. CIGNA had breached its promise to care about people proven through numerous

charges and fines against it including, among other things, wrongfully denying mental health

treatment claims. Additionally, CIGNA failed to respond to customer concerns online and in

57

popular forums, indicating that it does not care, when it has the capability to easily do so.

Additionally, CIGNA failed to care about people by failing to oversee how its partner American

Specialty Health was treating its members and ensuring that its partner is addressing complaints

and concerns in forums and on websites.

263. CIGNA breached its promise to act with courage when the need had arisen.

Instead of acting on concerns of fraud fellow employees, including the HR Manager, responded

with complacency allowing Plaintiff’s data access to be removed and the employee to be

suspended despite an ongoing investigation. Additionally, CIGNA representatives on repeated

occasions acted with severe intimidation against Plaintiff in order to bring shame and fear so that

he would be discouraged from pursuing a duty that is morally right. When tested, CIGNA

employees and representatives failed to act with courage and assist Plaintiff when he was trying

to look out for the best interests of the members.

264. CIGNA breached its promise to act with integrity on numerous occasions. Instead

of acting with truthfulness and honesty, CIGNA, among other things, has chosen to be evasive in

regards to how it has handled reported concerns of fraud and challenges against the organization.

265. CIGNA has failed in its promise to help keep people well. It has contradicted

expert opinion on, among other things, how it is accepting testosterone treatment claims for

people that don’t medically need it and where it could be medically harmful. Additionally,

CIGNA’s wrongful denial of treatment for nutritional (eating) disorders brought by the state of

New York could have put the health of those patients in serious jeopardy. Comments and

feedback left by hundreds of members pleading for help reinforces the fact that CIGNA is not

helping to keep many people well.

266. CIGNA has failed in its promise to a commitment to excellence by, among other

things, not upgrading to ICD-10 in a timely manner and by failing to evangelize change and

58

make change happen within its provider network and/or within the private health care industry

with regards to upgrading to ICD-10.

267. CIGNA breached its promise to investigate fraud when it pertained to Plaintiff’s

best interests. CIGNA did not perform an adequate impartial fraud investigation when put under

the requirement to do so. CIGNA, when presented with concerns of fraud, as well as documents

and evidence, failed to respond in a transparent manner in order to indicate that it was looking

out for Plaintiff’s best interests despite the fact that he was an IT employee that deserved rightful

privilege to this information.

268. Indiana Tennessee contract law recognizes the implied covenant of good faith and

fair dealing in every contract. Thus, implicit in its contract with Plaintiff were provisions

prohibiting CIGNA from engaging in unethical conduct that obstruct Plaintiff’s ability to receive

the benefits of the agreement and promises CIGNA made.

269. CIGNA acted in bad faith and breached the provisions of the agreement

specifically by not living up to its promises to care about people, demonstrate courage, act with

integrity, act with a commitment to excellence, help to keep people well, and investigate fraud

for Plaintiff’s best interests.

270. CIGNA was under an implicit obligation to be truthful in its advertisements. It

breached the promises made through these advertisements. CIGNA failed in its commitment to

excellence, to act with integrity, to help keep people well, to care about people, on numerous

occasions. In addition CIGNA failed to demonstrate courage and honor its obligation to

investigate fraud for Plaintiff’s best interests.

271. CIGNA breached the implied covenant of good faith and fair dealing by failing

to: (i) provide excellence, (ii) act with integrity, (iii) care about people (iv) help to keep people

well (v) demonstrate courage, (vi) investigate fraud for Plaintiff’s best interests.

59

272. The aforementioned breaches of contract have directly and proximately caused

Plaintiff economic injury and other damages, including in the amount of the difference between

the price he paid for CIGNA’s services as promised and the actual diminished value of its

services.  Further, as a result of misdiagnosis related to ‘Low-T’ treatment, Plaintiff has suffered

unknown damages.

273. Accordingly, Plaintiff seeks an order (i) preliminarily and permanently enjoining

CIGNA from continuing to engage in unfair and fraudulent conduct, (ii) requiring CIGNA to

pay damages in amounts to be proven at trial, and (ii) awarding Plaintiff costs and reasonable

attorney’s fees.

PRAYER FOR RELIEF

WHEREFORE, the Plaintiff respectfully requests that the Court:

A. A. Order Defendant to make whole the Plaintiff by providing him

with appropriate back pay, with pre-judgment interest, in amounts to be

determined at trial, and other affirmative relief necessary to eradicate the

effects of its unlawful employment practices, including but not limited to

front pay and lost future earningsThat this action be filed and served upon

Defendants in a manner prescribed by law;.

B. That the court enter a judgment against the Defendant;

C. B. That the court award Plaintiff damages in the amount of an

estimated one hundred million dollars as the court determines; which is

equal to his overpayment for health insurance premiums , and

compensatory es for the financial and ional harm (including mental

60

anguish, loss of enjoyment of life, pain and suffering); and loss of

earnings, future earnings; and current and future net worth as a result of

actions caused by Defendants, including prejudgment and post-

judgmeother damages permite

D. Order Defendant to make whole the Plaintiff by providing compensation

for past and future pecuniary losses resulting from the unlawful

employment practices described above, including out of pocket expenses

plus pre-judgment interest and future monetary expenses including but not

limited to job search expenses, in amounts to be determined at trialThat

the Court award Plaintiff payment of all fees, costs, and expenses,

including attorney’s fees and expert fees;

C. Order Defendant, to make whole the Plaintiff by providing compensation for past

and future non-pecuniary losses above, including physical and emotional pain and

suffering, mental anguish and loss of enjoyment of life, in amounts to be

determined at trial;

D. E. Order Defendant to pay the Plaintiff punitive damages for their

malicious and reckless conduct described above, in amounts to be

determined at trial.

E. Grant such further relief as the Court deems necessary and proper in the

public interest.

F. Award the Plaintiff attorney fees and costs of his action.

JURY TRIAL DEMAND

The Plaintiff hereby requests a jury trial by jury trial on all questions of fact raised by his

complaint.

61

Respectfully Submitted on this the 13th Day of October, 2014

_________________________________

Peter Bonewitz

62