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Arizona tribe sues Mashantuckets for millions over medical claims

An Arizona Indian tribe is suing the Mashantucket Pequot Tribal Nation in tribal court, alleging the Mashantuckets' Pequot Plus Health Benefit Services mishandled the White Mountain Apache Tribe's medical claims in 2007 and 2008.

Although a complaint filed in August establishes no figure for the damages sought, the amount at stake is estimated to be more than $6 million, according to the New London attorney representing the White Mountain Apache.

"That's an unusually high amount for a claim of this kind," M. John Strafaci said Tuesday. "That's what makes this case stand out."

The suit names as defendants Pequot Health Care, Pequot Plus Health Benefit Services and the Mashantucket Pequot Tribal Nation, which have yet to file a court response.

"As a matter of policy we do not discuss pending litigation," said Bill Satti, a spokesman for the Mashantuckets.

The White Mountain Apache Tribe, or WMAT, a sovereign tribe that occupies a reservation in east-central Arizona, sponsors a self-funded health benefit plan for tribal employees. According to the suit, the tribe hired Pequot Plus to provide third-party claims administration for the plan.

After Pequot Plus began administering claims, "WMAT's health care costs began to dramatically increase," says the complaint, prepared by Anthony Lee, a WMAT attorney.

The suit notes that members of the WMAT and all other federally recognized tribes are entitled to certain free health care coverage at facilities operated by Indian Health Services or the tribe. Such facilities may also refer tribal members to private facilities that provide covered services.

As more tribal governments introduced their own employee health plans, Congress recognized the need for the proper coordination of plans to ensure that tribal plans didn't pay claims the federal government should be paying, according to the suit.

The WMAT health plan, the suit says, is "a secondary payor."

In the two years before Pequot Plus assumed third-party claims administration for the WMAT plan, the denial of claims eligible for federal reimbursement saved the White Mountain Apache, on average, more than $2.7 million a year, the suit says.

The Arizona tribe terminated its contract with Pequot Plus as of Dec. 31, 2008 and retained another third-party claims administrator.

In the suit, the tribe alleges that Pequot Plus confirmed during an April 2009 conference call that it had failed to deny claims eligible for federal coverage, "resulting in the WMAT plan's paying medical claims that were the financial responsibility of the federal government."

The suit claims Pequot Plus breached its contract with the plaintiff and misrepresented its ability to provide third-party administrative services.

Chief Judge Thomas Weissmuller has been assigned to the case.

b.hallenbeck@theday.com

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