A recent federal lawsuit claims that health insurance company Cigna employed a computer algorithm to automatically reject hundreds of thousands of patient claims without properly assessing them, as mandated by California law.

According to the class-action lawsuit, which was filed on Monday in federal court in Sacramento, Cigna Corp. and Cigna Health and Life Insurance Co. denied over 300,000 payment claims within a span of just two months last year.

The lawsuit alleges that Cigna’s doctors, relying solely on the PXDX system, systematically turned down claims based on medical justifications alone, without ever examining the patients’ files. Consequently, thousands of patients were left with inadequate coverage and unexpected medical bills.

The lawsuit further claims that Cigna engaged in an illicit scheme intended to systematically and wrongfully deny claims, effectively evading the financial responsibility of covering essential medical procedures.

Cigna, headquartered in Connecticut, boasts a membership of 18 million individuals in the United States, with more than 2 million residing in California alone.

The plaintiffs in the lawsuit are two Cigna members from Placer and San Diego counties who were compelled to pay for their own medical tests after their claims were dismissed by Cigna.

Lawsuit Accuses Cigna of Violating California’s Medical Expense Investigation Requirement

A recent lawsuit has accused Cigna of not following California’s mandate to conduct “thorough, fair, and objective” investigations into medical bills. The lawsuit seeks unspecified damages and a jury trial in response to Cigna’s alleged violations.

Accountability Concerns and Denial Appeals

According to the lawsuit, Cigna utilizes the PXDX system, knowing that it won’t face consequences for wrongfully denying claims. The lawsuit points out that only a small fraction of policyholders actually appeal denied claims. This lack of accountability raises questions regarding Cigna’s claims review process.

Cigna’s Response

Streamlining Physician Reimbursement

Cigna further clarifies that their use of technology aims to ensure that codes for common, low-cost procedures are accurately submitted based on their publicly available coverage policies. This review takes place after patients have already received treatment, meaning it does not result in any denial of care. If codes are submitted incorrectly, Cigna provides clear guidance on resubmission and the appeal process.

The lawsuit will now proceed, and its outcome will determine whether Cigna’s practices comply with California’s requirements for medical expense investigations.

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