CIGNA Facing Lawsuit After It Denies Coverage for Liver Transport and Teen Dies

In a lawsuit that seems like a scene out of Michael Moore’s SICKO recent film on the U.S. health system, CIGNA is facing a lawsuit after it denied coverage to Nataline Sarkisyan who needed a liver transplant. The California teenager, 17, died at the University of California, Los Angeles Medical Center despite the fact that a match was found weeks previously. CIGNA HealthCare decided that the procedure was “too experimental” to try — or least pay for. Now, there is a called for manslaughter charges against CIGNA — and a likely tort action.

It could make for a compelling tort action, but will likely run into contractual and legal protections given to insurance carriers. The case may increase demands for state and federal legislators to examine those contractual and legal provisions. When death is the alternative, an “experimental” procedure is better than no procedure. Then again, I am only a juris doctor.

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27 thoughts on “CIGNA Facing Lawsuit After It Denies Coverage for Liver Transport and Teen Dies”

  1. Nice discussion Patty C and Jay!

    Jay, I appreciate your reply which was well spoken and not at all as ascerbic as my little rant was.

    Thank you and you have my best wishes.

    The juries really don’t let their emotions get out of control for the most part.

    Believe me the other side is very good at manipulating the same emotions!

    Excessive awards are often not granted. The appeals go up to the fed level and there is the elephant’s graveyard of many a large recovery.

    The jury pool nowadays has been exposed to 20+ years of “tort reform” dogma. They are as aware of run-away juries as counsel. You would be surprised how sophisticated they are.

    Economic damages are impossible to assess in most cases. What is the proper recovery for someone who is blinded at age 8 by a medical treatment error? How do you set a price on that?

  2. Read my earlier post as someone in the field.

    “That aside, the biggest problem is the injection of insurance companies into the treatment decision processes of patients whom they don’t know, in fact have never even met, yet over whom they exert ultimate approval authority on often life-saving procedures being considered about which they are equally unfamiliar.”

  3. So am I to interpret what you wrote as saying that we should cut defense spending and increase domestic “nanny funds” spending? No disrespect Patty C. but that is entirely off topic. That is why I can never EVER support a democrat, because they are notorious for subsituting a pointed finger for a solution. Give me a democrat with a backbone and I’ll give you my vote, until then the status quo will remain the same as long as we continue to point fingers. I really would rather not go into the Iraq issue, but for argument’s sake, to refute your argument that the costs have been “mind-boggling”. Really, mind-boggling? For the record, spending on the Iraq war is only running around 4% of GDP, relatively conservative for the
    defense budget throughtout history (just under 9% in 1991). I’m not trying to take any side on foreign policy here because I don’t want to get off topic, but I just wanted to state some facts.
    Why do I feel like I am the only one on here attacking the health insurance companies and the ridiculous system is encompasses? What do the doctors feel about this? I would love to hear from an M.D. on what he/she feels is the problem/solution.

  4. Here, here, DW. Couldn’t have said it better myself!
    Shorter, maybe ; )

    The smart money in the insurance racket is in collecting premium
    – not in paying claims.

    It’s startling to me that one thing that still needs constant repeating is we have allowed ourselves to be spent into oblivion for a ‘war’ in Iraq that we did not need to start in the first place.

    And when you consider, in addition to the losses of American soldiers and to their lives, the mind-boggling sums it’s costing, unnecessarily, it’s very easy to see where, given the choice, we would have spent more wisely and very differently.

    And the responsibility for that, my friends, should be placed squarely where it belongs.

  5. Please disregard the grammatical errors in the above post, my editor is on vacay.
    I also wanted to throw in there that another HUGE problem lies in the bureacracy of the system itself. In this case, it looked like the UCLA doctors were recommending an experimental treatment, and some HR rep was denying it. Why aren’t doctors given the overall authority, or at least MORE say in matters? In worse cases,if a person decides to sue the HMO, that type of litigation drags on forever, and the only thing accomplished is the attorney’s get richer. If you want to profit, short CIGNA’s stock for a little bit and use the proceeds to pay for your treatment.
    I would like for you to clearly define this “power block” as you put it. I will agree with you if it includes the block between the doctors and the HMO (or PPO God forbid) because there lies the problem, not the Bush administration Michael Moore.

  6. To deeply worried,
    It’s fair to say that “little old grandma” should be taken with a grain, nay, handful of salt. I know grandmothers in their forties, hardly little and certainly not old, so it’s hard for me to imagine a computer savvy, white-haired “little old grandma” taking the brunt of my abuse. I’ve been wrong before though, I remember that day.
    In all seriousness, I would like to make it clear that my intention was NOT to defend President Bush or support his policy (though it is clear from reading my post that is how it came across). I am a Republican but I don’t try to apologize for his countless mistakes in office. Where I draw the line is when people try to creatively bend ANY bad situation or event into yet another failure of the Bush administration. Believe me, he has plenty to pick from in plain sight, and you are right, THAT song will never grow old. But the lyrics, “I lost my job, my wife left me, my mortgage payment just got higher, my insurance company are robbing me blind..Way to go Bush, way to go Bush. Bush, Bush, Bush, Bush.” BTW I have had no formal songwriting education, not bad eh?
    I’ll agree with you that arbitration and mediation is usually a shady deal. But I will disagree with you on the notion that our jury system OF OUR PEERS is justice. Are you kidding? They will look at this case, let their emotions get the best of them, and award the plaintiffs $20 million, which in the end will take forever and the attorney will get a HUGE chunk of that. The problem is the tort system and it is in dire need of reform. Things won’t magically change when Bush leaves office.

  7. Jay, here you are taking a grandma, a little old grandma, to the woodshed! Shame indeed.

    You have to exercise some charity and see how Bush has come to be the flypaper for all the grievances of the country. There is something in the Bible about judging a tree by its fruits.

    And we (and you as well?) have seen the fruits of this Executive.

    No wonder people are ready to blame him for everything short of the wobble in the Earth’s orbit. His administration has had its fingers in practically all aspects of American life and I don’t see how they can escape the historians’ inevitable judgement as being worst administration this country has ever suffered.

    But Bush is just a lightning rod really. The true blame, you’re correct, should not be lodged at his doorstep.

    Its the power-block that has his back that is the real problem.

    That same power-block that has people like yourself convinced that the tort system and common law itself is defective and of course people shouldn’t really have access to the courts at all, should they? If this powerful element had its way, everyone would be reduced to seeking remedy from private arbitrators who in turn would be beholden to the insurers who hired them. People are so pesky, they keep complaining about defects in the tidy system of profits. Best to shear away their legal standing to bring suit. Let us have employment contracts and insurance policies that require arbitration for any grievance!

    So don’t blame Bush, blame the People. After all, those enormous recoveries you detest are awarded by juries after all; your fellow citizens who of course you probably think are manipulated by the nefarious trial lawyers.

    Oh the poor, poor health industry! Jay, have you ever been to Las Vegas? You should go there sometime if only to witness the conventions of corporate defense lawyers in everything from assisted living/nursing care practice, to medical malpractice. You should attend some of the break-out sessions where totally cynical defenses are discussed and test jury model data is gone over and the newest wrinkles presented.

    No, the corporate world has no dearth of defenders or expertise for that matter. Save your tears for them and chill your outrage at people who don’t agree with this corporate faux-utopia.

    Oh, and “the song” is not boring at all. New lyrics are being discovered weekly and you’re going to hear it sung more than you would ever like I suspect.

  8. To TennGrandma,
    Don’t go turning this into a “blame Bush” tactic; that’s an old, boring song. It has gotten to the point where some people are actually LOOKING for excuses to blame the president, and now you are using this poor girl’s death as another. Shame, shame on you.
    It would appear that the “bad guy” is the insurance companies. I won’t disagree, I hope they are successful in pursuing severe criminal penalties. But it is my opinion that the ROOT of the problem lies in our court system, and how punitive damages are sometimes awarded in tens of millions of dollars. That’s absurd, and that is why we have our healthcare is so damn expensive because people are sue-crazy. Don’t get me wrong, there should be some type of monetary penalty, but the real punishment should come in the form of jail time, not a fat check. You people are idiots to think the problem is with Bush…get over it already.

  9. Vincent,

    Your post is a model of good writing and powerful rhetoric.

    The system as it currently exists is stuck between the Scylla and Charybdis of no care versus excessive care and the insurers are denying coverage for huge swaths of the population while allowing for overuse of the system by the privileged few (I am one such, sad to say). In five years I have had five major surgeries and countless expensive diagnostic tests. This deducts from everyone else’s coverage or adds to their premiums. Or both.

  10. Further to your comments about “Love it Leave It!”: The dilemma has been transformed into an argument for Americans to duel, even though many of the most vocal of citizens against public or national health fail to realize the basis of the actual arguments, which have primarily been made by economists and investment advisers, and not health professionals.

    The entire argument has been converted and manipulated in such a way that many Americans actually believe that collectively taking care of each other via a good health care system for all – is frighteningly like Communism, but … turning over the Nation’s wealth, debt and credit to a huge war machine is some how comforting.

    Health insurance is a misnomer. It’s much like blackjack. Imagine if our highways were repaired via an insurance model. Or our drinking water clarified via an insurance model. Statistically, based on profit – quality of services would be more distinct than they are already based on future profitability and shareholder return as opposed to delivering excellent services or products, which was the starting point of the free market. We’ve already heard, most recently , that certain Fire Services in Southern California have been privatized by insurance companies in order to limit the risk of loss economically for paying claims on inflated real estate.

    Unfortunately, free markets aren’t actually free, another misnomer. The marketers may be free, but the buyers in the market are confined to what they can afford when the tail is wagging the dog, as is our current economic policy. Free market denotes a shopping experience of choices and varying quality. But supposed the alleged free market is subsidized secretly so that wealth is actually siphoned from an economic system, thereby making the system weaker. That’s what they did to health care. They convinced us that health care professionals were the enemy – and that health insurance was the answer – when in fact they have converted the wealth of the insureds to their stakeholders and lowered the quality of health care in general. Ultimately lowering the expectations of many – let them eat cake.

    We have daily affirmations by many in the health care industry that it is routinely failing. We are exposed to daily reports of insurance companies actually focusing on their prime object – return on investment – as opposed to delivering a health care fund cooperative via actuarial statistics and risk management.

    What happened then? How did this free-market philosophy become part of health care and why? Simple – there’s more money in insurance than there is in health care. Sad but true. Just as there is more money to be made in War – then in Peace. The only issue is … in these two particular cases – the citizens, are by and large, cheering wildly for their own abuse and ultimate destruction. This is the benefit of converting reasoned discourse into shouting matches of sound bites – much like competitive sports – which America seems hypnotically obsessed. When the Nation needs to be focused on understanding the actual identity of the hand they feel in their pocket – they are waving flags and gluing platitudes to the bumper of the car that decries they’re social standing in the community and their ability to shoulder incredible debt.

  11. Hey, CIGNA is just doing its thing…the American way.

    We don’t need no stinkin’ socialistic universal health coverage. Just ask the Rambo wannabes scrambling to become the next Puppet in the Oafel Office of the White House, and especially the pathetic Fred Thompson who can’t tell us often enough that he is the conservative and that he is the resurrected Reagan (who started our descending slide into the disaster we are in today).

    The Dupes in the benighted region of the Southern Strategy will come through with the votes necessary to continue the laissez-faire, every person for him/herself as every red-blooded freedom-loving American ought to be. If one should fall through the cracks economically as a result of a terrible event in one’s life, such as a disabling stroke or heart attack at age 35 or 40, then he should look to family or church groups for (inadequate) aid. As any lunatic in the ultra-right camp will tell you, “Get outta my face…why should my taxes support someone else? Move to a Communist country!” (This theme actually appears on some website posts.)

  12. While this is an excessively sad story, it is becoming commonplace at the altitude in which the health-care industry (as in insurance / medical services conglomerate) in general. Imagine, that many of us have a distant stake in this case because of Moore’s ‘Sicko’; yet, this story is a daily event, and the the greatest number of these stories are concealed from us through unimaginable deception.

  13. It is incredibly crass to see how our medical service is now being governed not by medicine or science or doctors but by the almighty dollar.
    How far we have come in our research and how low in our esteem for the preservation of life.
    This should be noted as one of the saddest moments in the proud history of freedoms in these United States of America.

  14. rcampbell,

    Agree completely with this post (and for that matter all your posts).

    Maybe an RC/DW ticket might make some sense after all!

    If only so we could make some much needed appointments.

    For Dept of Labor: John Edwards and goodness! would he have a job on his hands cleaning that place out.

    For Attorney General: Dennis Kucinich! Ditto. Just the bomb-thrower the place needs.

    For Supreme Court: Barack Obama and other not to be mentioned luminaries we both know.

    For Secretary of State: William Jefferson Clinton

    For Treasury: Oh well, we might put up Krugman or even put in Rubin again if he’s learned his lesson. The choosing criteria should be the rhetorical question: “Which candidate will cause the most foaming at the mouth at the WSJ op ed team’s office?”

    For Veterans Affairs: Jack Murtha gets the nod

    Recommend Senate Majority Leader: Joseph Biden or Dodd

    For HHS: Hillary Clinton

    For Homeland Security: forget it–we abolish that Stalinesque monstrosity.

    What say you? Any other ideas?

  15. How many times have we heard someone opposed to a single-payer universal healthcare plan railing about “…government bureaucrats making your healthcare decisions…”? Can someone explain to me how or why it’s acceptable to have a corporate bureaucrat making these decisions? In my understanding of a properly run universal healthcare program, there would be NO bureaucrats making such decisions. If you need a liver transplant or some other procedure, you get it.

    This is just one more thing that government does BETTER than the private sector–along with military, Social Security, police and fire protection, libraries, basic elementary/secondary education and others.

  16. The Billing Code is a number signifying the (type of) Procedure so that the Provider can get paid the standard fee allotted.

    There have been, in the past, plenty of instances where another Code has simply been applied to “experimental” and known effective procedures that is ‘close enough’, and is needless to say routinely, albeit unwittingly applied in error, and things ‘proceed’, fiscally, only to be straightened out at a later date.

    That aside, the biggest problem is the injection of insurance companies into the treatment decision processes of patients whom they don’t know, in fact have never even met, yet over whom they exert ultimate approval authority on often life-saving procedures being considered about which they are equally unfamiliar.

    I would love to see a cost/benefit ratio analysis study of how much insurance companies spend to employ how many professional Claims Specialists to deny claims, including surgeries, hospital stays, treatments, and prescriptions, and what the incentives are, both inside and outside those companies, for doing so.

  17. Wow! If only we had a government that cared about the American people… the insurance companies would be disbanded and we would have the health care that all “modern” countries have been granted. But, then, we are on our way backward and will soon be just another third world country.

    Way to go CIGNA – you killed another sick person. Are you proud? Congress, the Senate and president are complicit in this girl’s murder and should be prosecuted.

  18. On a personal note: when I myself “got” cancer, there was a surgical procedure available that had very good statistics for effectiveness. The only catch was that because it was new, it didn’t have any data for long-term outcomes. The procedure codes were not covered by my insurance provider as the procedure was viewed as still experimental and not medically necessary since alternative modalities existed.

    In cases like mine, if one has the means, one can bypass the insurers and just have the procedure…life is after all more valuable than one’s stock investments. However that’s not a viable option for the vast majority of people and it wouldn’t be a bad idea, if people are willing to take the risks of novel procedures, to have some kind of clause in one’s insurance that would raise the premium but at least provide some kind of coverage on such electives.

  19. This story was sad to see, but not unexpected. I didn’t know how bad the situation was in our health care system until I saw SiCKO. People are turned away for the most ridiculous of reasons.

    I’m sure in the future you will see a clearer definition of what is “experimental.” At least, I hope so.

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