Need Help with Cigna Health Insurance Claim Denial

copb8tx

copb8tx

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Jan 26, 2008
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In April of this year I had a signficant dirt bike accident in the mountains of Arkansas. I was transported to a trauma center hospital in Springfield, MO by helicopter. I had no say as to where they took me. It happens to have been a facility that was out of network for my Cigna heath insurance policy. While there it was deemed that I needed extensive surgery to my shoulder and that it was unsafe for me to travel back to Dallas to get this done. The surgery was performed at the MO facility. My policy states that I'm covered for out of network for emergency services.


Cigna has now denied the majority of the claim and is trying to leave me on the hook for over $145K. I've had it reviewed twice internally and they stand by their ruling however they have a dispute department that I can appeal to. This seems very one-side to me that they are the ones reviewing their own rulings.


So my question is, does anyone here have experience in this area? What should be my next course of action following the filing the dispute?


I've been dealing with this for 8 months and am a total loss.
 
Your second level appeal is generally conducted by an outside physician that it not affiliated with the Insurer, to remove bias/risk on the part of the carrier. This could be the third level review as I'm not familiar with DOI regs in these states. Proceed with caution on your final level of appeal/review as it is likely your last line of defense, so you'll want to ensure that the reviewer has all available information concerning your situation.
If you are part of a large employer group, it's highly likely that your plan is self-funded by your employer, meaning that they pay the claims and Cigna is just the administrator. If that is the case, raise your situation with your HR department as they will have "pull" with their account team to ensure that this is reviewed appropriately. In addition if the case is unique enough they may have the ability to make an extra-contractual payment to the provider on your behalf (extremely rare, but it does happen).
While members are generally protected against balance billing for out of network ER visits, surgeries can certainly lead to significant billing issues like yours. You'll need to ensure that there is thorough documentation from the hospital that it was a significant risk to move you, and that you were unable to influence/change that decision. Sorry to hear of your accident and situation happening with this, certainly not something anyone wants to have to deal with.
 
I'm glad you are okay.

Unfortunately CIGNA is managing their costs and believe they are on solid ground to deny your Claim. They do have an Appeal process but if it was me .....I would have a lawyer who practices Health Care litigation to write the Appeal. It appears that you live in Chicago and the accident was in Montana and without knowing the details of your Policy and more importantly the State laws of Illinois and Montana....you need to get the Appeal written so that the expenses will be approved. The best way to do that is by having an Attorney write the Appeal citing the appropriate State law that would be used if they chose not to approve the Claim.

A lot of Policies are written to exclude "dangerous activities" and "emergency procedures" that they don't approve as a means to limit their liability.
 
PlayDate said:
I'm glad you are okay.

Unfortunately CIGNA is managing their costs and believe they are on solid ground to deny your Claim. They do have an Appeal process but if it was me .....I would have a lawyer who practices Health Care litigation to write the Appeal. It appears that you live in Chicago and the accident was in Montana and without knowing the details of your Policy and more importantly the State laws of Illinois and Montana....you need to get the Appeal written so that the expenses will be approved. The best way to do that is by having an Attorney write the Appeal citing the appropriate State law that would be used if they chose not to approve the Claim.

A lot of Policies are written to exclude "dangerous activities" and "emergency procedures" that they don't approve as a means to limit their liability.
Click to expand...

Lives in Tx/Fl, accident in Arkansas and surgery performed in Missouri...
 
Thank you all for responding.

I have spent hours and hours and hours dealing with care providers and insurance trying to get this resolved. It's a total beat down. I really thought the $59K helicopter ride was going to be the issue but insurance paid most of that and I was left paying $4K. At that time I was so relieved I thought I was out of the woods. Didn't know there could be such issues with straight hospitalization.

I'm still not sure what's been more painful, the wreck or the financial aftermath.
 
Have you engaged any legal counsel to this point? That's a big bill. I wouldn't wait much longer...
 
Like mentioned already, if your plan is a large group plan with your employer it is likely an ASO - Administrative Services Only plan meaning that your employer actually pays the claims. If that is the case I would get your HR involved ASAP.
Hate to hear this - what a racket our healthcare is. Where else would you buy something without know what it is or how much it is going to cost. I figure the doctors are trying to make the best care decisions without cost being a factor -- but the aftermath from the financial part of the equation can be devistating.
 
Get a malpractice lawyer. I question the premise that you were too critical to have your surgery in Tx.

Cigna isn’t your enemy. That hospital is. Who, why, what about that decision that you couldn’t travel? Shoulder surgery? Something doesn’t sound kosher.

Unless you had damage to major organ(s) arteries, etc who made that medical decision that you couldn’t travel? That’s where your lawsuit will point.

35 years in healthcare talking.
 
Malpractice lawyer? Not the issue here. Get with your Insurance administrator (who sold the policy to your employer) know your policy, and appeal to the Office of the Commissioner of Insurance in your State.
 
@copb8tx I have operational experience with the insurance processes you are encountering. My experience is not with your carrier or in your state, but I can tell you how the process probably works and who is involved. It is too complex to explain in a chat board, but I would be happy to talk you through what is probably happening behind the scenes at the insurance company and also the options you might have with the hospital. Send me a DM and I would be happy to connect.
 
El Capitan said:
Get a malpractice lawyer. I question the premise that you were too critical to have your surgery in Tx.

Cigna isn’t your enemy. That hospital is. Who, why, what about that decision that you couldn’t travel? Shoulder surgery? Something doesn’t sound kosher.

Unless you had damage to major organ(s) arteries, etc who made that medical decision that you couldn’t travel? That’s where your lawsuit will point.

35 years in healthcare talking.
Click to expand...

Also had many broken ribs and a collapsed lung.

And the scapula was broken into 4 separate pieces. 12.5 hour surgery.
 
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spikedaddy99 said:
Malpractice lawyer? Not the issue here. Get with your Insurance administrator (who sold the policy to your employer) know your policy, and appeal to the Office of the Commissioner of Insurance in your State.
Click to expand...

Would that be the state I live, or the state I was cared for in?
 
copb8tx said:
Also had many broken ribs and a collapsed lung.

And the scapula was broken into 4 separate pieces. 12.5 hour surgery.
Click to expand...

Did they diagnose you with a pneumothorax? Is it in your medical record? Was there any thoracic surgery for it specifically?
 
El Capitan said:
Did they diagnose you with a pneumothorax? Is it in your medical record? Was there any thoracic surgery for it specifically?
Click to expand...

Ok, now you're talking a different language and I have no idea of those things. Layman's terms, I was in ICU 3 days and on a chest pump for 7. No surgery to the chest area, just the shoulder.
 
copb8tx said:
In April of this year I had a signficant dirt bike accident in the mountains of Arkansas. I was transported to a trauma center hospital in Springfield, MO by helicopter.
Also had many broken ribs and a collapsed lung.
And the scapula was broken into 4 separate pieces. 12.5 hour surgery.
I was in ICU 3 days and on a chest pump for 7. No surgery to the chest area, just the shoulder.
Click to expand...
Great Scott man! That sounds brutal. Glad you made it through and sorry about your insurance dilemma. Hope you get it sorted to your satisfaction.
 
I agree with you getting an attorney that specializes in healthcare policy and administration (not malpractice.) He will know the law in the relevant jurisdiction. Talking to the hospital or physician billing department will get you nowhere. And talking to their billing service is even more worthless. Additionally talking to your insurance company will also be a waste of time.

The answer to your problem lies in the details of your medical insurance contract and the jurisdictional state and federal law. Both of which will be well known and well understood by your future attorney. In my state surprise out of network billing is highly regulated and consumers are well protected in these cases as I am almost certain they are in your state too.

By the way...do not ignore this and let these "debts" wind up in collections as this will further complicate and entangle your situation. You must be proactive and work with your specialized attorney.
 
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+1 on the lawyer. 6 years of being the CFO of an 80+ attorney firm taught me when it is the right time to hire counsel. I guarantee you the insurance company has some and they have been through your claim and policy with a fine tooth comb. You are at a distinct disadvantage here.
 
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