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Cigna faces lawsuit over denied teen residential mental health care
The complaint says Cigna changed its denial reasons across multiple appeals and missed timely claim determinations, after doctors recommended residential treatment following an overdose.
A Colorado father has filed suit against Cigna, alleging the insurer denied his teenage son residential treatment that clinicians said was medically necessary. The complaint was filed September 22 in US District Court for the District of Colorado, and it is brought under ERISA, the federal law governing employer-sponsored benefit plans, on behalf of the minor child.
Insurance Business reports that the father alleges Cigna Health and Life Insurance Company refused to cover residential treatment and that the insurer kept shifting the basis for denial as the claims progressed. The suit says Cigna initially flagged the absence of a prior authorization on file and asked for more information from the provider, then later failed to make a timely claim determination and denied coverage on a different ground, calling the treatment experimental, investigational, and or unproven.
The teenager, who was diagnosed with multiple conditions including ADHD, persistent depressive disorder, generalized anxiety disorder with social anxiety features, and several substance use disorders, was first admitted to Elements Wilderness Program, an intermediate residential behavioral health program licensed in Utah, according to the complaint. The filing alleges that following a week-long period before admission that included an overdose on Xanax and alcohol, Cigna declined to process the claims, and a subsequent appeal was rejected as untimely.
After the teen moved to Crossroads Academy, another licensed Utah residential treatment center, the suit states Cigna again denied coverage, this time on medical necessity grounds using the MCG Behavioral Health Guidelines, which are described in the complaint as third-party criteria insurers use to assess whether the level of care is warranted. The lawsuit alleges the guidelines are unfair and biased against approving residential treatment claims.