Cigna Settles NY Wrongful Denial Charge

After an investigation uncovered the wrongful denial of hundreds of claims for nutritional counseling for mental health conditions, New York Attorney General Eric T. Schneiderman reached a settlement with Cigna Corporation, requiring the health insurer to reprocess and pay hundreds of claims for nutritional counseling for mental health conditions, in particular eating disorders, to members who were wrongfully denied those benefits.

Under the terms of the settlement, the company agreed to comply with Timothy’s Law, New York legislation enacted in 2006 and named for a 13-year-old Schenectady boy who committed suicide after an insurance company denied ongoing coverage for treatment of serious mental health issues, including hospitalizations.

“State law clearly requires health insurance companies to provide mental health benefits on par with other medical benefits. There is no gray area here,” Schneiderman said. “This settlement puts insurance companies on notice: My office will aggressively enforce mental health parity laws and fight to give patients the benefits they are legally entitled to – and which they pay for.”

Schneiderman’s Health Care Bureau launched an investigation into Cigna’s administration of mental health benefits following the receipt of a complaint, in 2010, from the family of a then 14-year-old girl living in New York City who suffers from anorexia nervosa.

The consumer complained that Cigna, which rejected all but three of her claims, had improperly denied coverage for nutritional counseling necessary for her mental health treatment. The company denied the benefit citing a limit of three visits per calendar year limit. Rather than jeopardize her health by stopping treatment, the consumer’s family continued the treatment, paying $2,400 out of pocket.

The settlement, the first one resulting from an ongoing probe into New York health insurance companies’ compliance with mental health parity laws, found that, since 2010, Cigna has denied more than 300 sessions of nutritional counseling to about 50 downstate members with mental health conditions, mostly eating disorders, on the grounds that the members exceeded the three-visit limit.

As a result, these members were forced to pay a total of approximately $33,000 out of pocket for this necessary treatment. While limiting nutritional counseling to three visits for behavioral health, Cigna, a global company with a nearly $30 billion in annual revenues, did not limit nutritional counseling visits for members with diseases outside the behavioral health realm – for example, for patients with diabetes.

The young woman’s doctor had determined that nutritional counseling was key to her recovery. Prior to treatment, due to her inability to meet minimal nutritional requirements, her body weight dropped to a dangerously low level and she developed osteopenia, a precursor to osteoporosis.

Her weekly visits to a nutritional counselor helped her develop balanced meal plans and an understanding of the implications of her poor eating behaviors. Nutritional counseling ultimately helped her reach an appropriate, healthy body weight.

Timothy’s Law mandates that New York group health plans provide “broad-based coverage for the diagnosis and treatment of mental, nervous or emotional disorders or ailments … at least equal to the coverage provided for other health conditions.” N.Y. Ins. Law §§ 3221(l)(5)(A); 4303(g)(1).

Timothy’s Law also requires that plans provide coverage comparable to that provided for other health conditions for adults and children with biologically based mental illness – including bulimia and anorexia – under the terms and conditions otherwise applicable under the policy. N.Y. Ins. Law §§ 3221(l)(5)(B)(i); 4303(g)(2)(A).

The New York law is similar to federal mental health parity laws, which were passed in 2008.

Under the Attorney General’s settlement, Cigna has agreed to eliminate the three-visit cap for mental health conditions and to reprocess and pay members whose claims were denied due to the limit, totaling approximately $33,000.

Cigna will also conduct in-service training for its claim and clinical review staff regarding the removal of visit limits for nutritional counseling prescribed for mental health disorders. Under the settlement, Cigna will also pay $23,000 to the OAG as a civil penalty.

Copyright © Corporate Crime Reporter
In Print 48 Weeks A Year

Built on Notes Blog Core
Powered by WordPress