Unjust Enrichment Claim Rejected: 6th Circuit Rules in Favor of Cigna in Emergency Room Billing Lawsuit

Emergency room visits can be financially devastating, especially when patients receive care from out-of-network providers. A recent ruling by the Sixth Circuit Court of Appeals in July of 2025 has significant implications for how hospitals and insurers negotiate these costs. The court sided with Cigna in a dispute over emergency room billing, rejecting an unjust enrichment claim brought by two Tennessee hospitals. This decision highlights the complexities of healthcare finance and the ongoing battle to control costs while ensuring fair compensation for medical services.

The Case: AMISUB (SFH), Inc. v. Cigna Health and Life Insurance Co.

The case, AMISUB (SFH), Inc., et al v. Cigna Health and Life Insurance Co., case number 23-5714, involved two hospitals, Saint Francis Hospital and Saint Francis Hospital-Bartlett, suing Cigna for allegedly underpaying them for out-of-network emergency services. The hospitals argued that Cigna was unjustly enriched by not fully covering the costs of these services. They claimed a quasi-contractual relationship existed, implying Cigna had a duty to pay reasonable costs. The hospitals provided emergency care to Cigna members as out-of-network providers after their price agreement expired at the start of 2019. They alleged Cigna consistently underpaid them for their emergency care, often paying them less than it paid to in-network providers. The claims were limited to care provided between January 1, 2019, and June 30, 2021.

The Ruling: No Contract, No Obligation

A three-judge panel of the Sixth Circuit upheld a lower court’s decision to dismiss the case. The court found that Cigna had no contractual obligation to provide full coverage for out-of-network emergency services. Without a contractual obligation or violation of state or federal law, Cigna was permitted to engage in balance billing, charging patients the difference between the cost of care and the amount the insurer was willing to cover. The court emphasized that the absence of an actual contract was critical to the outcome. The hospitals had dropped their breach of contract claim on appeal, focusing instead on unjust enrichment and quantum meruit.

Unjust Enrichment: What It Means

Unjust enrichment is a legal concept where one party benefits unfairly at another’s expense. In Tennessee, proving unjust enrichment requires showing that the defendant received a benefit from the plaintiff and that it would be unfair for the defendant to keep the benefit without paying for it. The Sixth Circuit found that the hospitals could not prove Cigna had been unjustly enriched because Cigna’s refusal to provide full coverage did not violate any laws.

Balance Billing and Its Implications

Balance billing, the practice of charging patients the remaining balance after insurance pays its portion, is a contentious issue in healthcare. While Cigna was cleared to continue this practice in this specific case, balance billing often leaves patients with unexpected and substantial bills. Many states have implemented laws to protect consumers from surprise medical bills, especially in emergency situations. The No Surprises Act, enacted in 2022, offers federal protection against surprise bills for out-of-network emergency care and certain non-emergency services delivered at in-network facilities. This act ensures patients only pay the cost-sharing amount they would owe for similar in-network care.

The Broader Context: Emergency Medical Treatment and Active Labor Act (EMTALA)

The Sixth Circuit acknowledged the challenges of balance billing, noting that emergency care doesn’t allow for pre-negotiated prices. Hospitals are obligated under EMTALA to provide emergency care regardless of a patient’s ability to pay. This federal law requires hospitals to treat any patient who presents to the emergency room, irrespective of their insurance status or ability to pay. This obligation can create financial strain on hospitals, especially when insurers like Cigna don’t fully reimburse for out-of-network care.

Differing Perspectives: Hospitals vs. Insurers

Hospitals argue that insurers have greater bargaining power and industry knowledge, enabling them to settle claims faster and easier than individual patients. They contend that insurers should bear more responsibility for ensuring fair reimbursement rates. Insurers, on the other hand, aim to manage costs and keep premiums affordable for their members. They argue that they are not obligated to pay inflated out-of-network charges, especially when no contract exists.

The Rise of Healthcare Litigation

The Cigna case is just one example of the increasing litigation surrounding healthcare billing practices. Disputes over reimbursement rates, ERISA violations, and surprise billing are becoming more common. These legal battles highlight the need for greater transparency and fairness in healthcare pricing.

What This Means for You

Know Your Insurance Coverage: Understand the details of your health insurance plan, including in-network and out-of-network coverage for emergency services.
Be Aware of Balance Billing: Be prepared for the possibility of balance billing if you receive care from an out-of-network provider.
Negotiate and Advocate: Don’t hesitate to negotiate with hospitals and insurers to lower your medical bills. Seek assistance from patient advocacy groups if needed.
Understand State and Federal Protections: Familiarize yourself with state laws and federal regulations like the No Surprises Act that protect you from surprise medical bills.

Do you have questions about medical billing disputes or need assistance navigating complex healthcare laws?

Contact our firm today for a consultation. Our experienced attorneys can help you understand your rights and explore your legal options.