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ProPublica released a scathing article on March 25, 2023, detailing the manner by which Cigna has systematically denied hundreds of thousands of medical claims in recent years by using automated systems which allow Cigna doctors to “instantly reject a claim on medical grounds without opening the patient file.” Claimants were left with unexpected bills and Cigna reaped millions in savings.

Many patients are not surprised. Patients often tell us that their claim was denied incorrectly, that the denial doesn’t make sense, that it doesn’t appear that anyone read their claim or medical information. The ProPublica’s investigation informs us that there is now evidence that this was happening for some of the 18 million people who are covered by Cigna insurance or whose claims are administered by Cigna.

Claimants were unwittingly subjected to the Cigna review process known as PXDX which let Cigna doctors reject claims without examining them. In short, Cigna sacrificed quality over speed and savings. The process allows Cigna doctors to sign off on denials in batches, one doctor stating, “It takes all of 10 seconds to do 50 [denials] at a time.”

Insurance companies, like Cigna, that insure health benefits and/or administer health benefits are expected to treat each insured fairly and meaningfully review each claim, said Dave Jones, California’s former insurance commissioner. Claimants are protected by federal and state laws. State insurance laws protect against insurance bad faith in denying claims. In California, health insurance companies may not deny health claims without a proper investigation.

The Employee Retirement Security Act (“ERISA”) requires that claimants receive a full and fair review for all health claims covered under ERISA. Too often insurance companies cut corners by not conducting full reviews, not investigating the merits of each claim, and not putting the interests of the claimant ahead of its own.

The ProPublica article has pulled the curtain back to reveal what many healthcare advocates and patients already knew or suspected was happening when claims were denied. When a health claim is denied, the insurance company must provide an explanation with reference to the provision of the insurance policy or health plan. A blanket denial for a batch of health claims cannot possibly provide a sufficient explanation or investigation into the claim.

Attorneys at Kantor & Kantor are dedicated to representing patients whose health benefits have been wrongly denied. We have challenged health benefit denials against all major health insurance companies through appeals and litigation. If you have a health claim that has been wrongly denied, contact us for a no-cost evaluation.