Cigna is facing a lawsuit that accuses the health insurer of inappropriately denying coverage for surgery services that were provided outside of an emergency department because of a surge in COVID-19 patients, according to court documents.
In a complaint filed Jan. 19 in the U.S. District Court for the District of Connecticut, New York resident Dinah Nissen accused Cigna of violating the Employee Retirement Income Security Act by refusing to cover her emergency facial surgery. According to her complaint, Ms. Nissen said she was bitten on her right cheek by a rescue dog on May 17, 2020. She went to the nearest urgent care center, where a New Hyde Park, N.Y.-based Northwell Health clinician advised her to seek immediate care from a plastic surgeon, according to the complaint.
Ms. Nissen said the Northwell clinician checked with two plastic surgeons who were on call in the emergency room at the closest hospital, Stony Brook Southampton (N.Y.) Hospital. According to the complaint, the on-call surgeon suggested that Ms. Nissen should be seen at his office rather than the hospital because of the large number of COVID-19 patients at the hospital.
After her procedure, Ms. Nissen received an invoice for the $10,300 procedure on June 16, 2020, which indicated the surgery was emergency, according to the complaint. She submitted a claim to Cigna on June 28, but the insurer rejected the claim on July 13, stating the surgeon wasn't in network and his billing codes didn't indicate an emergency.
Ms. Nissen appealed, the complaint states, and the surgeon's biller reached out to Cigna with a letter explaining that the surgery was completed in an office, not an emergency department, because of an influx of COVID-19 cases. However, Cigna maintained its denial based on the fact that the surgeon was out of network, according to the complaint.
Becker's Hospital Review reached out to Cigna for comment on the lawsuit, but did not hear back before the time of publication. This article will be updated as more information becomes available.