UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF PENNSYLVANIA
Dr. Jane Doe, M.D.,
individually and on behalf of all others similarly situated,
Plaintiff,
v.
Blue Cross Blue Shield et al.,
as representative of a defendant class of health insurance payers,
Defendants.
Civil Action No. ___________
CLASS ACTION COMPLAINT
JURY TRIAL DEMANDED
COMPLAINT
Plaintiff Dr. Jane Doe, M.D., individually and on behalf of all similarly situated licensed physicians, brings this class action against defendants, a class of health insurance payers, and alleges as follows:
I. NATURE OF THE CASE
This action seeks to remedy the unjust, uncompensated administrative burden imposed on physicians by the requirement of prior authorizations (PAs) demanded by health insurance companies as a condition of coverage.
Defendants, acting as a class of payers, have imposed upon physicians the obligation to complete and submit PAs without compensation, in order to receive payment for services already determined to be medically necessary.
Plaintiffs seek monetary relief of $30 per prior authorization submitted to any defendant payer, a reasonable estimate of the administrative cost and labor imposed on providers.
II. JURISDICTION AND VENUE
This Court has subject matter jurisdiction under 28 U.S.C. § 1332(d) (Class Action Fairness Act), as the amount in controversy exceeds $5 million and the class includes members from multiple states.
Venue is proper in this District under 28 U.S.C. § 1391(b) because one or more defendants reside in, are authorized to conduct business in, and regularly transact substantial business in this District.
III. PARTIES
Plaintiff: Dr. Jane Doe is a board-certified physician licensed in Pennsylvania. She has submitted hundreds of PAs to health insurers without compensation and represents a class of similarly situated providers.
Defendants: A defendant class composed of health insurance payers operating in Pennsylvania and across the United States, including but not limited to:
Blue Cross Blue Shield entities
UnitedHealthcare
Aetna/CVS Health
Cigna
Humana
Pharmacy Benefit Managers (e.g., OptumRx, Express Scripts)
Pennylvania Medicaid
Federal Medicare
IV. CLASS ACTION ALLEGATIONS
Plaintiff brings this action under Fed. R. Civ. P. 23(a) and (b)(3) on behalf of a class defined as:
"All licensed physicians in the United States who submitted one or more prior authorization requests to any health insurance payer within the past four (4) years."
Numerosity: The proposed class includes 4 thousand physicians across the Commonwealth of Pennsylvania, making joinder impractical.
Commonality: Common questions include:
Whether PAs constitute uncompensated labor;
Whether insurers are unjustly enriched;
Whether compensation of $30 per PA is reasonable.
Typicality: Plaintiff’s claims are typical of the class. All class members face identical harm.
Adequacy: Plaintiff will fairly and adequately protect the interests of the class, and has retained experienced class action counsel.
V. FACTUAL BACKGROUND
Prior authorization is an administrative process where insurers require physicians to obtain approval before providing medical services or prescriptions.
This process requires time, administrative staff, clinical review, and legal risk — all borne by the physician without compensation.
Insurers benefit financially by delaying or denying care through PA systems but do not share the administrative cost burden.
National studies estimate the average cost of PA completion to be between $25 and $35 each, depending on specialty and complexity.
Any agreement between insurers and physicians that purports to waive compensation for the administrative labor of prior authorization is a contract of adhesion. These agreements are presented to physicians on a take-it-or-leave-it basis, with no meaningful opportunity to negotiate terms.
Such agreements are procedurally and substantively unconscionable. Physicians are compelled to sign them under economic duress to access patients covered by the defendant insurers. The waiver of compensation for a valuable and time-consuming administrative service constitutes an unconscionable forfeiture of labor without just compensation.
Accordingly, any provision in these agreements purporting to waive compensation for the performance of prior authorization tasks is void and unenforceable under state common law principles of contract and equity.
Physicians are ethically and legally bound by their duty of care to their patients. When an insurer demands a prior authorization before agreeing to compensate for medically necessary treatment, the physician is placed in an impossible position: either perform uncompensated labor or deny treatment to the patient.
This coercion strips physicians of meaningful choice and compels them to complete administrative labor under threat of harm to others — namely, the denial of timely or life-saving treatment to their patients. This pressure is not economic alone but moral and professional, arising from medical licensure, duty to care, and professional standards.
Such compelled, uncompensated labor, undertaken under duress and threat of harm to third parties, constitutes a form of involuntary servitude in violation of the Thirteenth Amendment to the United States Constitution.
VI. CAUSES OF ACTION
Count I – Unjust Enrichment
Defendants benefited by offloading administrative duties onto providers without compensation.
It is unjust for payers to reap the cost savings and delay benefits of PAs while requiring free labor from physicians.
Defendants may attempt to rely on participation agreements or insurance contracts to disclaim liability for payment. However, any such contractual provision is void as unconscionable and does not bar restitutionary relief.
Count II – Quantum Meruit
Plaintiff and class members rendered a service (PA completion) with the reasonable expectation of payment.
Defendants accepted the benefit and must compensate at a fair rate ($30 per authorization).
Even if express contracts exist between the parties, recovery in quantum meruit is appropriate where the contract is unconscionable or void, and services have been rendered with the expectation of compensation.
Count III – Declaratory Judgment (28 U.S.C. § 2201)
An actual controversy exists as to whether prior authorization paperwork constitutes compensable labor.
Plaintiff seeks a declaration that insurers owe compensation for all future prior authorization requests imposed.
Count IV – Injunctive Relief
Plaintiff seeks to enjoin the practice of requiring uncompensated prior authorizations as a condition of reimbursement for medically necessary care.
Count V – Violation of the Thirteenth Amendment (42 U.S.C. § 1983)
The Thirteenth Amendment prohibits slavery and involuntary servitude, except as punishment for a crime.
Physicians, by virtue of their licensure and professional obligation to act in the best interest of their patients, are compelled by insurance companies to provide prior authorization services without compensation under threat that their patients will be denied necessary care.
This system of coercion forces providers to labor involuntarily, not for public service, but for the financial benefit of private corporations — the defendant health insurance payers.
Defendants' policies and practices amount to a form of private, compelled labor with no meaningful alternative, and thus violate the Thirteenth Amendment. Plaintiffs seek declaratory and injunctive relief to bar such practice, and statutory damages under 42 U.S.C. § 1983.
VII. PRAYER FOR RELIEF
WHEREFORE, Plaintiff respectfully requests that this Court:
A. Certify this action as a class action;
B. Award $30 for each prior authorization submitted by class members in the past four years;
C. Enter declaratory judgment that insurers must compensate physicians for future PAs;
D. Enjoin the practice of requiring uncompensated administrative labor from physicians;
E. Award attorney's fees and costs under applicable law;
F. Grant such other and further relief as the Court deems just and proper.
VIII. JURY DEMAND
Plaintiff demands a trial by jury on all issues so triable.
Respectfully submitted,
