Hecht v. The Cigna Group, 1:24-cv-05926

Plaintiffs Andrew and Andrea Hecht sought emergency medical treatment for their son at Edward-Elmhurst Hospital, where Andrew also received treatment; they were insured through Cigna under an employer-sponsored plan.
Cigna processed the Hechts’ claims as in-network, making them responsible for 20% coinsurance, but the hospital billed them as if it were out-of-network and sent the unpaid balance to collections despite Cigna's assurances.
The Hechts repeatedly contacted both Cigna and the hospital over two years to resolve the billing/narrative discrepancy, to no avail; the issue impacted their credit.
Cigna told the Hechts the hospital had been in-network, promised to escalate the issue, but did not follow up or resolve the dispute.
The Hechts filed suit under ERISA § 502(a)(1)(B) (benefits due) and § 502(a)(3) (fiduciary breach), alleging Cigna mishandled their benefits and failed to rectify the network dispute; Cigna moved to dismiss.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Denial of benefits under ERISA § 502(a)(1)(B)	Cigna failed to pay all benefits due and did not resolve the network status error, resulting in extra charges	Cigna paid all benefits as required by the plan; no Plan term violated	Dismissed; no plausible claim that Cigna denied any plan benefits or breached specific terms
Failure to resolve network dispute (contractual duty)	Cigna should have ensured hospital abided by in-network terms and prevented balance billing	No contractual obligation to force providers to accept Cigna’s adjudication; Plan does not guarantee enforcement of network status	Dismissed; Plan does not require Cigna to compel hospitals to follow in-network billing
Fiduciary breach under ERISA § 502(a)(3)	Cigna failed duty of care/loyalty by not resolving network dispute, shifting costs to members	At most, Cigna made a mistake but had no intent to harm or deceive; mere miscommunication is not a breach	Not dismissed; Hechts plausibly allege breach of fiduciary duty based on failure to protect their interests or resolve provider dispute
Administrative exhaustion	Not required; appeal process did not apply and would have been futile because there was no adverse benefit denial	Plaintiffs failed to exhaust Plan’s required appeals procedures	Not dismissed; exhaustion excused because no denial of benefits for review and Plan’s process did not cover this type of dispute

Tolle v. Carroll Touch, Inc., 977 F.2d 1129 (7th Cir. 1992) (establishes that ERISA § 502(a)(1)(B) claims are creatures of contract law)
Larson v. United Healthcare Ins. Co., 723 F.3d 905 (7th Cir. 2013) (describes § 502(a)(1)(B) as providing a contract remedy under the plan)
Williamson v. Curran, 714 F.3d 432 (7th Cir. 2013) (documents attached to a complaint are part of the complaint for motions to dismiss)
Allen v. GreatBanc Tr. Co., 835 F.3d 670 (7th Cir. 2016) (outlines the pleading standard for breach of fiduciary duty claims under ERISA)
Kenseth v. Dean Health Plan, Inc., 722 F.3d 869 (7th Cir. 2013) (negligent misstatements to insureds are not actionable as fiduciary breaches under ERISA)