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In the interest of full disclosure, I am an attorney, a CPCU, and have almost 20 years in the insurance world. In addition, I have some experience as a personal injury attorney. I have never, and will never, work for a health insurer.
If you haven't seen the story, CIGNA has been accused of killing a young woman in California by denying a Liver Transplant. Teen Dies, Cigna Blamed
Anyone with a heart has to feel for the family of the girl; however, insurance policy should be based upon facts, not emotion. So far, we know the young lady was extremely ill with leukemia. She received a bone marrow transplant from her brother. Unfortunately, the transplant led to complications and her liver was failing. Furthermore, other organs were damaged. UCLA was willing to do a liver transplant; however, there is no evidence a liver would have been found in time to save the girl.
Apparently, CIGNA denied the initial request to pay for a liver transplant on the grounds it was experimental; however, they later changed their minds. It appears public pressure played a role in this decision.
In analyzing the coverage issue, we need to determine two things:
- Did CIGNA break the insurance contract?
From what we know, CIGNA had some sort of appeals process built into their claims process and the appeals process appears to have been followed. Given the unique nature of her treatment needs, I don't believe it was unreasonable to have a 2nd opinion before spending an enormous amount of money on a treatment that may not work.
- Did CIGNA act in "bad faith" by denying the initial request?
If the initial denial was a breach of contract, was it in "bad faith?" Given their response to the appeal, I think not.
My take – this tragic situation was not a case of an insurance company looking to screw the little guy. If not "experimental," the treatment was certainly aggressive. If you pull the claim file from CIGNA, I would bet the farm they had real doctors, not "bean counters", make the ultimate decision.
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