# Williams v. Cigna Health and Life Insurance Company

> District Court, E.D. Missouri · April 21, 2022

URL: https://www.frixlaw.com/law-library/cases/10236963

## Case

- **Court:** District Court, E.D. Missouri
- **Decided:** April 21, 2022
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

- No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases.
- Full citator and citing cases: https://www.frixlaw.com/law-library/cases/10236963

## How later opinions describe it (automated extraction)

- holding that under the circumstances “discovery [was] unnecessary to establish the existence of a conflict”

## Opinion text

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MISSOURI
EASTERN DIVISION

J.W. (a minor) by and through his legal )
guardian BRUCE WILLIAMS, )
)
Plaintiff(s), )
) Case No. 4:21-cv-00324-SRC
v. )
)
CIGNA HEALTH AND LIFE )
INSURANCE COMPANY, et al., )
)
Defendant(s). )

Memorandum and Order

J.W., a minor, suffers from anxiety, depression, and other psychological and behavioral
disorders. Cigna denied coverage for mental-health services J.W. received at three residential-
treatment centers, and after he appealed the coverage decisions administratively, J.W. sued in
this Court, seeking benefits under his father’s employee-benefit plan. J.W. now moves to permit
discovery outside the administrative record, arguing that potential conflicts of interest and
various procedural irregularities justify departure from the general, no-discovery rule.
I. Background
As discussed in the Court’s prior order, Doc. 40, J.W.’s Second Amended Complaint
alleges that J.W.’s father is “an employee of Barry-Wehmiller Companies, Inc. and is a vested
participant in a Group Insurance Policy which provides an employee benefit plan within the
meaning of 29 U.S.C. § 1132(a).” Doc. 20 at ¶ 5. J.W. alleges that his father is a “participant in
the ERISA medical benefits policy that is administered by Cigna, and his dependent child, J.W.,
is a beneficiary of those medical benefits under the Plan.” Id. at ¶ 7. Putting aside the counts the
Court previously dismissed, Doc. 40, J.W. alleges that Cigna wrongfully denied him benefits
under his father’s employee-benefit plan for medically necessary mental-health services, in
violation of the Employee Retirement Income Security Act of 1974 § 502, 29 U.S.C. §
1132(a)(1)(b). Doc. 20 at ¶¶ 49–77.
J.W. now seeks to conduct limited discovery outside the administrative record to

investigate potential conflicts of interest and procedural irregularities that may have affected
Cigna’s claims-review process, and the parties fully briefed the motion. Docs. 45, 46, 54, 55, 60.
As revised in J.W.’s reply, the outside-the-record discovery J.W. seeks includes: (1) production
of claims handling manuals and procedures; (2) the depositions of three Cigna employees; and
(3) production of compensation guidelines for medical reviewers including information about
bonuses. Doc. 60 at pp. 6–7.
II. Standard
The parties agree that the Court will apply the abuse-of-discretion standard when it turns
to the merits of the case. Doc. 54 at p. 4; Doc. 60 at p. 1; see McIntyre v. Reliance Standard Life
Ins. Co., 972 F.3d 955, 959 (8th Cir. 2020). Under this deferential standard, the court limits its

review of the administrator’s benefits determination to the evidence before the administrator at
the time the administrator denied the claim. Jones v. ReliaStar Life Ins. Co., 615 F.3d 941, 945
(8th Cir. 2010). For this reason, courts generally do not allow discovery outside the
administrative record. Id.; see Atkins v. Prudential Ins. Co., 404 F. App’x 82, 84–85 (8th Cir.
2010). “However, limited discovery may be permitted to determine whether a conflict of interest
or procedural irregularity exists.” Moore v. Sedgwick Claims Mgmt. Servs., Inc., No. 4:19-cv-
2513, 2020 WL 2494590, at *2 (E.D. Mo. May 14, 2020) (citing Sampson v. Prudential Ins. Co.
of Am., No. 4:08-cv-1290, 2009 WL 882407, at *2 (E.D. Mo. Mar. 26, 2009)); see Jones, 615
F.3d at 945 (holding that under the circumstances “discovery [was] unnecessary to establish the
existence of a conflict”). To secure outside-the-record discovery, J.W. must show good cause,
which in this context means “establishing that the administrative record is insufficient to
establish a ‘palpable conflict of interest’ or a ‘serious procedural irregularity.’” Woodrome v.
Ascension Health, No. 4:19-cv-2638, 2020 WL 1479149, at *2 (E.D. Mo. Mar. 26, 2020)

(quoting Farley v. Ark. Blue Cross & Blue Shield, 147 F.3d 774, 776 n.4 (8th Cir. 1998)).
III. Analysis
The Court first addresses J.W.’s conflict-of-interest argument and then considers whether
any of the alleged procedural irregularities justify outside-the-record discovery.
A. Conflicts of interest
In his motion and memorandum in support, J.W. does not allege the existence of any
conflicts of interest justifying discovery. Docs. 45, 46. Indeed, the administrative record
establishes the absence of a payor-administrator conflict because Barry-Wehmiller self-insures
the plan and Cigna administers it. Admin. R. (AR) at p. 690 (Bates), Doc. 53-6 (“The benefits . .
. are self-insured by Barry-Wehmiller Companies, Inc. which is responsible for their payment.

Cigna Health and Life Insurance Company (Cigna) provides claim administration services to the
plan, but Cigna does not insure the benefits described.”); cf. Metropolitan Life. Ins. Co. v. Glenn,
554 U.S. 105, 108 (2008) (“Often the entity that administers the plan, such as an employer or an
insurance company, both determines whether an employee is eligible for benefits and pays
benefits out of its own pocket. We here decide that this dual role creates a conflict of interest.”).
In reply, J.W. pivots to a different argument. Admitting that no structural conflict exists
in this case, J.W. claims that the lack of a payor-administrator conflict alone “does not guarantee
that there are not other conflicts at play.” Doc. 60 at p. 6. J.W. then states he “has determined
that additional discovery is necessary in order to determine that Cigna’s physician’s [sic]
reviewers do not have a financial incentive to deny claims.” Id. Putting aside for the moment
that J.W. improperly raised this argument and discovery request for the first time on reply, J.W.
fails to assert any facts, either in his complaint or with this motion, supporting the existence of a
conflict of interest. Because “[a] mere assertion of bias based on nothing more than speculation

fails to show good cause to allow discovery beyond the administrative record,” Woodrome, 2020
WL 1479149, at *2 (citing Westbrook v. Georgia-Pac. Corp., No. 4:05-cv-1331, 2006 WL
2772822, at *4 (E.D. Ark. Sept. 26, 2006)); see also Westbrook, 2006 WL 2772822, at *4 (“It is
not enough to allege generally that ‘a conflict of interest may exist’ or that the case ‘may have
procedural irregularities.’” (internal quotation marks omitted)), the Court denies J.W.’s request
to conduct conflict-of-interest discovery.
Additionally, J.W. improperly raised his conflict-of-interest argument on reply. “Courts
generally do not review arguments first raised in a reply brief because the other party has not had
adequate opportunity to respond to such arguments.” Bayes v. Biomet, Inc., No. 4:13-cv-800,
2021 WL 3330911, at *8 (E.D. Mo. Aug. 2, 2021) (citing Fish v. United States, 748 F. App’x 91,

92 (8th Cir. 2019)). Because J.W. provides no good reason justifying his untimely argument, the
Court denies his request for conflict-of-interest discovery on this basis as well.
B. Procedural irregularities
J.W. contends that three procedural irregularities require additional, outside-the-
administrative-record discovery. See Waldoch v. Medtronic, Inc., 757 F.3d 822, 830 (8th Cir.
2014) (holding that, to affect the Court’s review under the abuse-of-discretion standard, “a
procedural irregularity must rise to the level of a ‘serious breach of the plan trustee’s fiduciary
duty to the plan beneficiary’” (quoting Menz v. Procter & Gamble Health Care Plan, 520 F.3d
865, 869 (8th Cir. 2008))). First, J.W. says that Cigna failed to properly investigate and gather
enough information before denying him coverage. Doc. 46 at p. 6–7. Second, J.W. argues that
“Cigna failed to properly apply its guidelines regarding residential mental health treatment for
Children and Adolescents.” Id. at 8–9. And finally, J.W. alleges that Cigna failed to abide by
certain ERISA regulations. Id. at 9–10.

However, even granting J.W. the vital assumption that these three allegations constitute
procedural irregularities, the mere existence of procedural irregularities does not establish good
cause for discovery. Instead, as mentioned, because “[a] palpable conflict of interest or serious
procedural irregularity will ordinarily be apparent on the face of the administrative record or will
be stipulated to by the parties,” Farley, 147 F.3d at 776 n.4, “[a] plaintiff must show good cause
for such discovery by establishing that the administrative record is insufficient to establish a . . .
serious procedural irregularity,” Moore, 2020 WL 2494590, at *2 (emphasis added and internal
quotation marks omitted). This limited-discovery regime “ensure[s] expeditious judicial review .
. . and [ ] keep[s] district courts from becoming substitute plan administrators.” Brown v. Seitz
Foods, Inc. Disability Benefit Plan, 140 F.3d 1198, 1200 (8th Cir. 1998). Here, J.W. fails to

show the insufficiency of the administrative record.
First, J.W. claims that Cigna failed to gather “any medical evidence” before denying J.W.
benefits for lack of medical necessity, thus requiring “discovery into: (1) how the denial was
made; and (2) if medical evidence was not relied upon to make that determination, what was?”
Doc. 60 at p. 4. J.W. also takes issue with the fact that Cigna initially authorized coverage from
one provider after phone calls between Cigna and that provider but no transcripts from the calls
exist, id. at p. 2, though the administrative record reflects the details of the calls, AR at pp. 157–
166, Doc. 53-2. In response, Cigna disputes J.W.’s characterization of the facts, but confirms
that the “records utilized” during Cigna’s review “are those produced in the Administrative
Record.” Doc. 54 at p. 7.
In reply, J.W. does not directly dispute Cigna’s assertion that Cigna produced all the
documents its reviewers considered and instead rhetorically implies—without a factual basis—

that the reviewers may have considered other information. Doc. 60 at p. 4. Putting such
speculation aside, see Woodrome, 2020 WL 1479149, at *2, because the administrative record
contains the information on which Cigna relied in making its coverage determinations, when the
Court turns to the merits, it need only consult the administrative record to determine whether
Cigna failed properly to investigate J.W.’s claims and whether Cigna abused its discretion in
denying coverage. See Farley, 147 F.3d at 776 n.4 (“A . . . serious procedural irregularity will
ordinarily be apparent on the face of the administrative record or will be stipulated to by the
parties. Thus, the district court will only rarely need to permit discovery and supplementation of
the record to establish these facts.”); see also Menz, 520 F.3d at 871 (“If a conflict of interest is
not apparent from the record, the district court may permit discovery. . .”). Thus, the

administrative record suffices for the Court to determine the existence of the first asserted
procedural irregularity.
Second, J.W. alleges that Cigna’s claim-reviewing physicians improperly applied Cigna’s
own “Criteria for Continued Stay” when determining the medical necessity of J.W.’s mental-
health treatment. Doc. 46 at pp. 8–9 (quoting AR at pp. 684–85, Doc. 53-5). For example, at
one point Cigna apparently denied coverage for the reason that “[J.W.] had not developed new
symptoms and/or behaviors that required this intensity of service for safe and effective
treatment.” AR at pp. 532, 562, Doc. 53-2. J.W. says that Cigna’s “Criteria for Continued Stay”
require authorization of benefits under such a circumstance, not denial. Doc. 46 at p. 9. J.W.
contends that “[t]his irregularity is so apparent,” yet he claims that he needs discovery to develop
the issue further. Doc. 60 at p. 5. But to determine whether this constitutes a procedural
irregularity, the Court can simply read Cigna’s regulations and compare them with the reasons
given by Cigna for denying J.W.’s claim. Simply put, the administrative record contains all of

the evidence the Court needs to determine if Cigna followed its own rules. Thus, the
administrative record suffices for the Court to determine the existence of the second asserted
procedural irregularity.
Finally, J.W. alleges that Cigna failed to follow the ERISA regulations governing what
information the notifications of adverse benefit determinations must include, and that this
constitutes a procedural irregularity justifying discovery. Doc. 46 at pp. 9–10 (citing 29 C.F.R. §
2560.503-1). However, in both his memorandum in support and his reply, J.W. admits that
“[t]he claim file makes it apparent that Cigna failed to follow many of [the ERISA regulations].”
Id. at p. 9; Doc. 60 at p. 5; see AR at pp. 764–853, Doc. 53-8. Because the administrative record
suffices to establish this purported procedural irregularity, Cigna’s alleged failure to follow the

regulations cannot justify outside-the-record discovery. See Woodrome, 2020 WL 1479149, at
*2; see also Menz, 520 F.3d at 871. When it turns to the merits, the Court can look to the
administrative record to determine if Cigna failed to follow the regulations. See Farley, 147 F.3d
at 776 n.4. J.W.’s bare statement that Cigna’s “failure to comply with the ERISA regulations are
[sic] grounds to discover if it failed to follow any additional regulations,” Doc. 60 at p. 5–6,
likewise does not justify outside-the-record discovery, Woodrome, 2020 WL 1479149, at *2 (“A
mere assertion . . . based on nothing more than speculation fails to show good cause to allow
discovery beyond the administrative record.”). Thus, the administrative record suffices for the
Court to determine the existence of the third asserted procedural irregularity.
IV. Conclusion
In this case, the administrative record readily establishes the existence of the
circumstances J.W. calls procedural irregularities. See id. (a “serious procedural irregularity will
ordinarily be apparent on the face of the administrative record. . .”). Because J.W.’s conflict-of-
interest argument rests on “mere assertion[s] of bias based on nothing more than speculation,”
and because J.W. fails to show “that the administrative record is insufficient to establish a...
‘serious procedural irregularity,’” id. (quoting Farley, 147 F.3d at 776 n.4), the Court finds no
good cause exists for discovery outside the administrative record and denies J.W.’s [45] motion.
So Ordered this 21st day of April 2022.
Ce
STEPHEN R. CLARK ere
UNITED STATES DISTRICT JUDGE

---

Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10236963. Public record. Not legal advice.