CIGNA Changes Mind About Paying $9700 Surgery Bill

Ahhh, the second of the insurance stories has trickled in and it’s a rip-roaring doozy.

Bodily mutilation
Kafa references
Indomitable and persistent consumer
Victory, snatched from the jaws of defeat, snatched from the jaws of abject incompetence.

Here’s a teaser line: “Then I got the surgery. Trust me, getting my face sliced up was the easy part.”

Tom’s letter, inside.

Tom writes:

“Hi –

This will probably be one of the better insurance stories you receive. But you gotta read to the end because this thing ends like a good book.

In March 2003 I scheduled surgery for nasal polyps (ok, that part of the story isn’t very good). I called my insurance company, CIGNA, to get preauthorization for the surgery (or what they call a predetermination of benefits). I also requested and received a predetermination for the surgeon I was to use. Finally, I requested and received a predetermination for the hospital the surgery was to be performed at. In short, I did everything I could imagine to make sure I didn’t get screwed by CIGNA.

I got the surgery in late March 2003. When I checked into the hospital, I provided my insurance information and listened while the hospital verified it with CIGNA, described the surgery and the surgeon, reviewed the treatment history, etc.

Then I got the surgery. Trust me, getting my face sliced up was the easy part.

Precisely 30 days later, I called the hospital to ensure they had been paid. They had not. So I called CIGNA to ask why. CIGNA assured me payment in full had been approved and was scheduled.

Thirty days later, same thing. Payment was approved, there are no problems, you have nothing to worry about, the bill will be paid.

Thirdy days later, same thing.

One week later I call again (the plan at this point was to call them every week, and then every day, until they paid). At this point, however, the story changed. As Donald Rumsfeld might say, goodness gracious did the story change. I was advised – 97 days after surgery, approximately 120 days since surgery was “pre-approved” – that CIGNA wouldn’t pay one nickel of the hospital’s charges. That hospital, they informed me, didn’t participate in CIGNA’s plan and was unauthorized. I was politely informed it would be up to me to pay the $9700 hospital bill.

The volume of telephone calls that ensued over the subsequent 9 months would take far too long to describe, so at this point I’ll greatly condense things.

I contacted my doctor – was I crazy, or didn’t he tell me his staff had verified all this stuff as well? His staff informed me they had. In fact, the hospital they used was the only one in the region with the medical equipment required for this surgery. It wasn’t possible at any other hospital.

I called CIGNA back and told them. Well, yes, the CIGNA representative told me, perhaps we would have authorized treatment with that information, but you didn’t provide it at the time.

I asked her, well, the doctor also confirmed coverage at that hospital. In fact, the hospital itself confirmed coverage before AND after surgery. We’re not imagining this. We have names and times and badge numbers.

This, word for word, was CIGNA’s response: “Well, sir, it was a clerical error. You know, mistakes happen.”

A-ha, I thought. They admit it was their own fault!

I then called the Ohio insurance commission (the body that regulates insurance companies in Ohio). Very proudly I described the situation to a case worker. I proudly described CIGNA’s admission that they had made a mistake, that it was their fault.

This, word for word, was the Ohio insurance commission’s response: “Well, sir, it was just a clerical error. Mistakes happen.”

Yes, I replied, but it was THEIR error, not mine. I was politely informed that it didn’t matter – I still had to pay for it, not them. The only determination of benefits that matters, I was told, was the one they make when the get the bill. That is, AFTER the treatment has already taken place.

In other words, I did all my homework, crossed all my t’s and dotted my i’s, got badge numbers and predetermination-of-benefit codes, and made sure the hospital and doctor did as well – and none of it mattered. Not one bit. Nothing counts until they get the final bill. That’s when a binding decision is made. In Ohio, there is no way to ensure a procedure will be covered before you undergo that procedure. This, somehow, constitutes “insurance.”

Just to wallow in the Kafka-esque glory, let’s recap: CIGNA pre-authorized everything. CIGNA even told me that since the hospital I used was the only one available with the necessary equipment, they would have approved it if I had told them that fact. But I didnt’ tell them that fact because I didn’t know I needed to, because they told me they would cover it regardless. And they admitted it was their error, and they were terribly sorry. But they still wouldn’t pay. Think about that for a moment. Try to imagine how these clowns live with themselves.

So I filed an appeal. A few weeks later, I got in contact with a company in New Jersey that represents screwed claimants like me. I decided to let them file an appeal on my behalf, so I told CIGNA to cancel my appeal and I would resubmit it. They said ok. They even sent me a letter stating the appeal had been cancelled. A new appeal, prepared by this company in New Jersey, was submitted.

To condense this story even further, on FOUR separate occasions over the next nine months, CIGNA told me my appeal had been approved, and on these FOUR occasions when the hospital never got paid and I called CIGNA back, CIGNA told me that information was a “clerical error” and the appeal had NOT been approved. FOUR TIMES. FOUR FUCKING TIMES.

This story has a great ending – hang with me.

After eight months, my resubmitted appeal was denied. Terribly sorry, said CIGNA, but it seems the surgery itself wasn’t necessary, so we are considering demanding back the money we paid your surgeon, too. He may bill you. The approval for surgery (not the facility approval, but the actual procedure approval) was – wait for it! – a “clerical error.” That’s another $5000 or so I’m now on the hook for. In fact, I interpreted this message as a threat, an attempt to intimidate me from pursuing the hospital charges.

I was despondent. I gave up.

One month later, I get another letter from CIGNA. I couldn’t imagine what it was for – my appeal had been denied. Game over. I lose.

The letter says, we are happy to tell you that the appeal you filed on July 3 has been approved and payment will be made to your facility provider. Wha?!

Turns out my first appeal – the one I cancelled, the one for which cancellation was verified in a letter CIGNA sent me – was never actually cancelled. So two appeals were in the system. The second one was reviewed first and rejected. The first one was reviewed second, and even though it contained essentially the same set of facts, it was approved.

Terribly sorry. Clerical error. The bill’s yours, CIGNA.

See a pattern here?

The moral of the story is, NEVER EVER USE CIGNA.”


Edit Your Comment

  1. Avery says:

    I thought the point of an insurance policy was to, like, insure you.

  2. bambino says:

    I’m so tired of insurance companies and their shell games, it makes me want to move to a deserted island a la Cast Away.

  3. any such name says:

    Jeeeeeeeeeeeeeeeeesus fucking christ.
    Glad my employer switched from Cigna to BCBSIL.
    At least I think I am….

  4. DeeJayQueue says:

    so, did they pay for the procedure or what?

  5. Kluv says:

    Fantastic story.

    I’ve been through the same thing with my crap Empire BC/BS HMO. Long story short, after an emergency appendectomy (performed at an in-network hospital) they refused to pay the anetheseologist or surgeon: “DUE TO A PRE-EXISTING CONDITION”.

    That’s right, they tried to say my almost-exploded appendix was a pre-existing condition and the wouldn’t cover it.

    Needless to say, over a year later, umpteen monthly phone calls, appeals, denials, and a collection agency threatening to come after me; the moons aligned and I finally got the ONE CSR who finally listened, understood, and helped fix the problem.

    And yes, their exuse? Clerical error. This is what I pay $654 per month for.

  6. Well this certainly puts my problem in perspective!

    The Ohio insurance commission should also share some of the blame in this. What’s the point in having a regulatory commision if they just let the companies make the clients pay for their mistakes anyway? They should have backed Tom up and the left him to twist in the wind.

  7. Pacificare increased my rates last year and 2 weeks ago without informing me, reduced my benefits and increased my co-pay.

    Insurance companies are amongst the most corrupt, greedy, soulless institutions in this country. They’re single-handedly responsible for reducing the quality of healthcare here.

  8. creamsissle says:

    With that logic, a customer’s failure to pay the premium on time could be a “clerical error”, too. Something tells me, though, that this lame excuse only works when it’s in the company’s favor.

  9. why not says:

    So, are there any insurance agencies that cover other insurance agencies mistakes/clerical errors/omissions/and the such?, because I might be up for it….

  10. Jupiter Jones says:

    Thank god I live in a sane country that doesn’t pour its health money into insurance companies pockets for this kind of results.

    Try moving to Canada where this sort of thing is free. You walk in, show your card, have the surgery and leave. No bills show up later, no collection agencies chase you.

  11. SO, according to thier logic, any surgery you have done, pre-approved or not, is simply a roll of the dice on whether they are going to cover it or not? So just get the surgery and cross your fingers that it won’t make you 10G’s in debt. Very comforting.

  12. gotbock says:

    No, the point of insurance companies is not “to insure you”. The point of insurance companies is to take your money in premiums, then make damn sure they never have to pay any of it out in compensation.

  13. Yep says:

    That stinks. (heh)

    Icing on the cake – I see three sponsored links at the bottom of this very page, all hawking health insurance quotes for… CIGNA Insurance.

  14. ‘Thirdy’ days?

  15. amazon says:

    Shhh Jupiter – we don’t want them to move here and use up all of our healthcare.

  16. I see three sponsored links at the bottom of this very page, all hawking health insurance quotes for… CIGNA Insurance.

    Oh lordy, I see one for BCBSGA. I had insurance from them through my employer from October of last year until the first of this year and I NEVER got an insurance card from them.

    I kept calling but come to find out at the end of the year that my street address kept getting cut off in their system because it was too long. Who puts a limit on the number of characters used in an address?

    By that time it didn’t matter because they changed to a different insurance company.

  17. Paul D says:

    I can see it now: “Insurance insurance”.

    I think that might be the goal, why not.
    It’s a conspiracy to get us to pay more.

  18. Morgan says:

    That’s why I’ve always maintained that insurance is a scam; statistically speaking, you will always pay more into insurance than you get out. This must be the case because insurance companies make money. This is why I hate that California requires you to have auto insurance to drive- I’ve never been the cause of an accident (I was rearended once), but I’ve paid several thousand in insurance just in case I will someday, by which point I will almost certainly have paid more into insurance than it will cost them to fix the problem. Then they will start charging me more even though I’ve made them more money than they’ve paid.

    Sorry for the rant. In useful information, to answer Rectilinear Propagation’s question, every company that stores addresses in a database puts a limit on the length of an address because database fields must be given a set length. Generally you try the field so long that no address will reach that length, but they either screwed up when setting up that database (underestimating the number of characters that will be needed) or you have an amazingly long address that no one could have predicted.

  19. mschlock says:

    Holy crap. That is an impressive level of douchery.

    I had a much less interesting dispute with my insurance company last year over whether or not my doctor was in-network. Luckily, I was able to turn the whole thing over to my HR department and their magic “corporate account” contacts. They knocked the requisite heads together and I got my money back after a mere three months (sigh).

  20. TedSez says:

    How about this?

    A. The whole thing was done on purpose.

    B. They’re doing it to thousands of other people right now.

    C. How many people would have been as persistent as you were? All they have to do is have their staff send out denial letters whenever possible, and they can save millions of dollars every year out of the money they would have had to pay for “approved” procedures.

    D. Why doesn’t everyone e-mail a copy of this post to CIGNA and tell them that practices like this are why you’ll never buy insurance from them. They clearly have no moral compunctions against this sort of thing, but they might think twice if they see that it’s affecting their bottom line.

  21. Ass_Cobra says:

    The issuer here is that most end users are not the purchasers of health care. Obviously we pay for it, but we don’t direct the purchasing, this is done by the benefits department of your employer. Their goal is not to get you the best health care but to get the most “benefits” at the lowest cost.

    There’s a fundamental disconnect when the individual making the purchasing decision has utility different than the ultimate consumer. It’s like having a goddamned interior decorator, you can’t get a lot done without them, you usually pay 30% markup and you rarely end up with anything you enjoy.

    The US needs to quit this travishamockery of “private healthcare” and move to a public system. Certainly not all of the elective surgeries are covered, but the fact that we spend a larger portion of our GDP on healthcare and achieve worse outcomes, by any objective measure, than the rest of the industrialized world is a clear indication that something is broken.

  22. ckilgore says:

    Remember that episode of the Simpson’s when the Flanders house gets destroyed? Maude says “Oh, we don’t have insurance. Ned considers it a form of gambling.” I am starting to see his point.

    I have been dealing with a similar situation from when my husband got his wisom teeth taken out in November 2005. Still running around with them now. I would have written in about it, but I don’t even know where to start.

  23. Ran Kailie says:

    I just went through something similar with BCBS, I saw a surgeon in June for a consultation regarding breast reduction, he recommended I have it done as soon as possible to have 2400 grams or more removed. I have grooves in my shoulders and trouble sleeping and breathing.

    They put a request for authorization in to BCBS. I received a denial letter because:

    “There is no proof that this has been an ongoing issue.”

    WHAT? Thats right I just suddenly sprouted boobs of mammoth size. And to add insult to injury:

    “The patient has provided no proof of spending at least 12 months attempting to cure her ailments through other means.”

    Other means? What other means? Living on pain killers which could give me something worse in the long run? After some back and forth my surgeon’s office got them to approve it. But I’m very paranoid about having the surgery and them denying it and then I have to fight with them over it.

  24. tell-it-right says:

    The insurance companies run the State of Ohio. Didn’t you know that? Who runs the insurance companies? The lobyist silly. Who’s the lobyist funded by? Back to the insurance companies which is held by private corporate earning shell partnerships that control most other businesses as well like banking and large retailers. If you follow the money look 1st into what holding companies own what and how many of the same board members sit on each others board. Doesn’t take a genius to ask for a prospectus or annual report from supposed public companies.