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September 12, 2023

Cigna sued for allegedly using ‘automated intelligence’ to deny claims without doctor review

Photo | CoStar Cigna headquarters in Bloomfield.
By Michelle Tuccitto Sullo

A class action lawsuit has been filed against Bloomfield-based insurer Cigna, claiming it has used automated intelligence technology to deny medical care claims - sometimes within seconds.

The lawsuit was filed in U.S. District Court in Connecticut Aug. 25, and it makes similar claims to one filed against Cigna in federal court in California in July. 

The lead plaintiff for the latest lawsuit is Paige Van Pelt, a Minnesota woman, though it was also filed “on behalf of others similarly situated.”

Van Pelt has Lynch Syndrome, which can create a genetic predisposition to cancer, according to the lawsuit. Because of this, she needs a colonoscopy every one to two years. In 2018, Cigna automatically denied coverage for her colonoscopy and endoscopy, because the clinic coded it as diagnostic instead of preventative. Van Pelt was billed $3,200, which has since been set to collections, according to the lawsuit.

The defendants include The Cigna Group, Cigna Corp. and Cigna Life Insurance Co. 

Attorney Joseph P. Guglielmo of Scott+Scott Attorneys at Law LLP, based in New York City, who represents the plaintiffs, claims in the new lawsuit that Cigna has “implemented sophisticated automated intelligence capabilities to systematically defraud consumers by denying medically necessary claims en masse without appropriate physician review.”

The lawsuit claims Cigna used an automated intelligence system referred to as “procedure-to-diagnosis,” or “PxDx.” The litigation alleges the insurer’s automated review program automatically denied without review more than 300,000 claims in a two-month period, spending an average of 1.2 seconds on each claim.

The lawsuit asserts denials without appropriate physician review violates state and federal consumer protection laws.

The litigation further claims members of the class have had to pay for medical services that should have been covered and paid by their insurance. It alleges Cigna has saved “millions, if not billions, of dollars,” through the practice, since most patients will typically pay the bills or forgo procedures, rather than appeal a denial.

The lawsuit alleges breach of contract and violations of the Connecticut Unfair Trade Practices Act,  Connecticut Unfair Insurance Practices Act and the Connecticut Corrupt Organizations and Racketeering Activity Act.

Cigna Healthcare issued a written statement denying the claims and any wrongdoing.

“This copycat suit is baseless and seems to erroneously assume that every claim goes through Cigna’s “Procedure to Diagnosis” (also known as “PxDx”) review, when in reality, only a small subset of services do,” the statement said.

According to Cigna, based on its research, the claims outlined in the complaint were not subject to Cigna’s PxDx review.

“To be clear: patients are not denied care through PxDx because the review takes place only after they receive treatment, and most do not experience any additional costs even if a claim is denied,” the statement added. “Procedure to Diagnosis is a simple process that helps accelerate payments to clinicians for common, relatively low-cost tests and treatments, and it is not powered by AI or an algorithm.”

Cigna asserted that it is an “industry-standard review” similar to processes used by the company and its peers for years. 

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