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Cigna Disability / STD Denial

1 United States Review updated:

My wife had surgery which resulted in a great amount of pain that she continues to life with. She went to numerous doctors over a period of months before the diagnosis was found to be a trapped nerve. While having to live with excruciating, continuous pain & trying to find the root cause of the problem; we had to deal with a company (cigna) who makes your life more of a living hell than it already is. Continuously asking for documentation & picking the doctors' words & phrases that justify their right of denial while completely ignoring wording that would not. Delaying, denying & hoping that you'll become so aggravated & demoralized that you eventually give up.
I honestly don't understand how these people can sleep at night knowing the misery they are causing people who depend on short term disability to live and then compounding it with enough paperwork from doctors that would keep a part time secretary busy - when they know they're just going to deny it anyway.
I haven't wished ill on anyone in years but I hope there is truly karma for all the people in cigna (esp Rachael Z) who have caused my wife & I so much stress & worry through all this. You are one ### company.

Ro
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Comments

  • Ca
      14th of Oct, 2011
    0 Votes

    Yeah it's always a hard lesson one learns when they realize that insurance companies only maintain a facade of compassion, while ruthlessly guarding profit margins for their shareholders.

  • El
      14th of Oct, 2011
    0 Votes

    All of the insurance companies look to deny STD claims. I have the same issue with the "wording" . My doctor says they are notorious for that. The pick point A and pick point Z and say they need to understand how they got the conclusion. My doctor said if they would actually review doctor visit notes, they would have their answer. Ask them to have a telephone conference with the doctor, if they keep blowing you off.

  • Jb
      14th of Oct, 2011
    0 Votes

    if only insurance companies worked like that...it costs more money to try to do exactly what you think they are doing. doctors have no clue as to what is going on. if it wasnt for their billing department, they wouldnt ever get paid because they know absolutely nothing about insurance billing. Yet, they always act like they know about it.

    with the days of technology, there is hardly any hands on claim processing. claims processing is handled by a computer system that automatically processes claims. claims may need manual review depending on what it is and that is where you will have someone review the claim, and process it with the need for more documentation.
    but, did you know it is actually a doctor that reviews the information that they recieve? so, if a doctor is reviewing the information and saying it isnt legit, more info needed, whatever...what does that tell you?
    the doctor that works for the insurance company does nothing but look over the information that they recieve. they dont deny the claim or anything of that sort other than to give feedback to the company as to what he determined from the written documentation.

  • El
      14th of Oct, 2011
    0 Votes

    JB, I have been dealing with my case since June. The specialists that responds first says documents are missing. My doctor's office was constantly re-faxing. Then they deny it saying the only issue mentioned was "lumbar pain" and it isn't enough to qualify. They ignored the MRIs, the doctor visit notes, and more detailed information about the injury and why the doctor recommended the limitations (based on the the condition, which was substantiated with. X-rays and MRIs). It was the claims appeal specialist that said the next step was for the insurance company to contact the doctor, since I was appealing the decision. The specialist was trying to explain that they needed to understand how the doctor came to the conclusion on my limitations. She said they see the injury (condition) and the recommended limitations but don't know how he made the decision. My husband joked in the background " he went to school to learn how to do his job"...meaning that he is a doctor and he took all of the facts and his medicL training and was able to make the decision. I told the doctor to expect the call and he said they are notorious for this. He says it is in his medical notes he included in the fax; if my condition itself wasn't enough to for the insurance company to understand why he stated the limitations, his notes were more than clear. I only wish it were simple as you say it is...

  • El
      14th of Oct, 2011
    0 Votes

    And my doctor never pretended he has anything to do with billing...he is there to treat my injury and to fill out the forms needed (FMLA, etc)...

  • Jb
      14th of Oct, 2011
    0 Votes

    i understand all of that. i deal with insurance on a daily basis. but, what doctors and a random person doesnt realize is that one persons conclusion can be incorrect. just because you are seeing one doctor, sure he may be right. but, he could be wrong. they would want to substantiate everything tied together. an MRI/ct scan, etc are going to show images of a possible problem. the doctors notes are going to back up his "theory".
    there isnt a single person that is an internal working person that is 100% medically trained other than the doctors that that are hired to do medical claim reviews. i would stake my career on the fact that the doctor is questioning something that he sees in the informaton that is sent and questions why your doctor is coming up with what he is.

    im not sure how Cigna works exactly, but when money is dealt with, they have to make sure it is going for a purpose.
    I wont disclose which insurance i deal with, but i can tell you this, its not the insurance companies money that they are using to pay for claims. its the money that is put in by the employer and the employee (group insurance). when dealing with other peoples money, that employer expects the insurance to make sure money isnt getting expended recklessly.
    the piddly amount of the claims that your dealing with, trust me its piddly, compared to the millions of dollars shelled out on a daily basis. i have seen 1 single check to 1 single provider that was almost 2 million dollars. think about it...they arent out to steal your money, as much as you would like to think so. i thought the same until i actually got into the biz. its far from the truth.
    i would stake a claim on this to say that SOMETHING isnt adding up when they review your information. it isnt one single person that is going to be dealing with it nor is it just on a whim that they will deny something unless there is soemthign suspect.
    My GF also works for an insurance company...seperate from me. she works in provider/patient fraud. neither me nor her could give a damn less about the claims that come in. obviously we do in the people aspect. but, when she reviews something, she is going to look at the information and base her decision on the informaton at hand. her approving or denying something has no effect on her. she doesnt get bonuses or anything of the sort. im in the same situation. the claims i see, all i see is information. i dont get anything out of doing anything differently. the people you deal with at an insurance company are there to make a paycheck and do the job they were hired to do. THEY DO NOT HIRE PEOPLE TO SIMPLY DENY CLAIMS FOR NO REASON. everything is based on information. you wont hear anyone say "im just going to deny this claim because i dont like them/ill get a bonus if i deny this/"enter diabolical reason here"".

    it really is that simple. most people will only believe what their doctor says because their doctor would never lie. doctors are far from perfect and most problems are caused by their own billing department. but for short term disability, its something that gets abused alot and they have a reason why they have to ensure that it isnt fraud. fraud in the end, causes your premiums to raise. im sure you have a legit claim...not questioning that. but, to ensure that money isnt being abused, insurance companies will do their homework and request alot of information. i see it happen alot with chiropractic claims. insurance companies will almost always request medical notes because once it stops being therapeutic and not helping anything, they will deny it unless medical notes show progress.

  • Jb
      14th of Oct, 2011
    0 Votes

    also to mention, if your doctor says "insurance companies are notorious for this" it sounds like HE has this issue alot.
    when a physician has a red flag for questionable claim that are frequent more often than not, he may be getting watched for fraud.
    the physicians that have a fraud flag are hassled alot with paperwork requests. keep that in mind also. that is only an educated theory, so dont take my word on it. but, that is a possibility since STD is a commonly abused system

  • El
      14th of Oct, 2011
    0 Votes

    I go to two doctors: a chiropractor AND a MD. They have separate practices and their diagnosis is the same. I don't think it is a joint effort and that we are all in collusion to defraud the insurance company.

    I am not saying the 'frontline' insurance reps are the people who necessarily looking to deny the claims. I think it is the system. Similar to the example of banks. People think the reps don't want refund the OD fees and the reps are heartless, but they are following a system. Where I feel there is a difference is the bank policy is black and white and I do not think the insurance company is reviewing claims with the goal approving claims that are valid but looking for reSons to make them invalid. Losing paperwork numerous times is 'questionable', focusing on lumbar pain, while that is a minimal part of the claim, in the decision making of the denial is ridiculous. My favorite is " your doctor didn't make of disabled on the form and he didn't state you CANNOT work". If I was totally disabled, I would be able to claim SSI, not STD. My doctor was not going to lie and put his practice in jeopardy and I wouldn't want him to. Also, he sYs it is not his place to say I CANNOT work; it is his job to state my limitation. It is the insurance company's job to review that my limitation make it impossible to do my job, even if I can do another job. The medical accommodations could not be made, so according to the ADA, that makes me eligible for STD. Again, the insurance company denies the claim by disregarding the facts or focusing on only on minor piece of the condition.

    My doctor saying they are notorious? That doesn't make him the wrong party. I have more faith in the healer who has helped me and has nothing to gain with his diagnosis. Who has 30 plus years of experience. I tend to question the incompetencies of the handling of the claim, the reputation for trying to deny might be true, they have something to gain by denying, and the reps who have reviewed the claim are not doctors and probably not as tenured in this field as my doctor is in his.

    You seem to be taking it personally. I am not ranting, yelling that insurance reps are heartless ( like other posters have). I am basing my opinion on my experience and mentioned the 'hear-say' I have heard. I am trying to be patient and follow the procedure to get the claim approved. But I am an experienced business woman and I filed a claim that is valid; the way it is being reviewed just does not seem to be productive or being processed with the goal of approving -and it seems their goal is to find a reason, any reason, to deny.

  • Jb
      14th of Oct, 2011
    0 Votes

    im not taking it personal, but it does irk me that people assume they know how it works just from the "heresay" that they get from friends, internet, doctors, etc. im simply trying to educate you in this. i am basing my words off of experience and not heresay or words spoken by someone else.

    you may not think "My doctor was not going to lie and put his practice in jeopardy" by trying to defraud anything. But, what about the doctors that commit fraud daily. their patients would think that the world is as peachy as you think and say that their doctor wouldnt ever do anything like that either. but, since people are imperfect and greedy, it is a possibility.

    "I do not think the insurance company is reviewing claims with the goal approving claims that are valid but looking for reSons to make them invalid. "
    with this, it goes back to the representatives being cruel and punishing. the person reviewing it is basing everything that they are doing off of paperwork that is presented. i guarantee that if you had the ability to have a sit down and explanation session with the person doing the review, you would get a whole new understanding of what is needed or any of the reasons. right now, your just a third party hearing something that was told to someone else and may not be getting told the truth or the full story.
    that "representative that is reviewing your information is following procedures. their procedure isnt to find a reason to deny something. it is going to be to question anything that can be questionable. there isnt a reason to question something if its 100% valid and complete. and yes, there will be multiple doctors that work with insurance companies. the people that work for an insurance company arent medically trained. it isnt their place to say that something isnt valid for whatever medical diagnosis or procedure. they will have a doctor review the information as well and consult. all major insurances have a physician consultant that is an MD. my girlfriend deals with an MD consultant all the time for fraud claims to verify the validity. in fact, if you look at job postings for major insurances, you will see job openings for those consultant positions.

    its human nature to try to save face when they are wrong. is it possible that something wasnt faxed-yes ; is it possible that a fax wasnt recieved-yes; is it possible that the doctor isnt telling you everything-yes ; is it possible that the doctor is trying to save his reputation-yes ; is it possible that the doctor is being fraudulent-yes ; is it possible that this whole situation could be because the information isnt explaining enough-yes.
    on the same token, yes, it could be complete incompetance of your insurance. but, you are focusing on the insurance thinking that it couldnt possibly be the fault of the doctor. and that is the part that really digs on me. people think that their side of the story couldnt ever be incorrect. ...as you will see in almost 80-90% of the complaints on this website.

    im not trying to be argumenative by any means and i apologize if it seems like it. But, insurance, banking, law, arent easy subjects to grasp because of so many different procedures that are not seen. people usually only focus on the wrong being done to them. the person doing your review isnt being devious and doing this purposely. it would have saved the company money and manpower to have paid this instead of requring multiple reviews and research.

  • El
      15th of Oct, 2011
    0 Votes

    Maybe I shouldn't have generalized by saying ALL insurance companies -but based on my issue and from what I have heard, it sounded like a safe assumption.

    My doctor has nothing to gain because I am paying him, regardless of the claim. The insurance company pays ME, if the claim gets approved. Can't see where greed would be a factor.

    Also, I gave all of the information to open the claim; yet a week later I get a call saying they can't proceed because they do not have the initial information to open the claim. The information I spent 15 minutes on the phone providing. Red flag. And as far faxing goes, the doctor's assistant gave me a copy immediately AFTER they faxed it.

    I don't see how this makes my doctor at fault.

    I understand what you are saying but in for this claim, even though it is personal to me, nothing leads me to believe it is the doctor -not the insurance company. And I am not saying it happens in every case, but I am convinced of it here.

    And just to show you I am not saying all of this because of my lack of insurance process knowledge, or because I am 'sour', or that I am going by hearsay; I have had my attorney review the issue and verifies it is a valid claim as well as say that the insurance company is not processing it properly ( he used different verbiage).

    No apologies necessary. It is just a healthy difference of opinion. All I ask is for an open mind because my reality may be different than your experience.

  • Jb
      15th of Oct, 2011
    0 Votes

    although, i would imagine that you probably do have a legit case, there are crooked providers regardless. i am going to make a general statement that is not directed toward you. but, providers will do things to get a better outcome for the patient which is another form of fraud.
    i see it happen pretty often with normal medical stuff. a provider will change diagnosis's and procedures to either help the patient pay less or to completely benefit themselves.
    having a lawyer look at something really doesnt make anything true. hes an attorney not a doctor or anyone that deals with insurance. he will build a case with the information at hand and piece in anything else with smooth talking. lawyers have the ability to build cases without having to know insurance or all of the facts. the information you have, any lawyer can piece something together and make it sound good. lawyers are all about smooth talking and persuasion. in the end, they have only enough informaton to be dangerous and to pressure the insurance into doing something just to avoid court proceedings.

    in the end, you have to remember that the person working your case is someone that really gains nothing from approving or denying your claim. they are taught how to look for things and need information to make an educated decision. it really is that simple. that person doing the review is not being coerced by any other factors. in fact, that person is practically a customer service person that works for a paycheck and goes home at the end of teh day doing the job with the guidelines they have to follow.

    but, i cannot say it enough, all insurance companies have doctors on staff that review the information. if that doctor questions anything, the person that is doing your case is going to bring up that question as well. no one in the insurance field is medically trained so, they arent pulling this out of mid air. i again, cannot say it enough that the person reviewing it is not "the insurance company". people will generalize insurance companies as one big monster just as i would a lawyer. but, i think lawyers are bad because i havent worked in the legal system to see how it really works. which brings me to the real point. until a person works in the biz, everything that is told to them, although some may be true, everything that is said is complete heresay unless that doctor, lawyer, etc has actually worked in the field directly.
    i cannot vouch for what Cigna is doing exactly because i dont know their appeal process. But, there are many things that are universal like required information and the actual people that review that information.
    i get requests to correct claims all day. most of them are preventative. or at least, the patient thought so. but, what is recieved by the insurance is what is processed. nothing more nothing less. and yes, some of the escalations i deal with are legit reasons and we simply do what we can to fix our error. but, if information is needed, its needed. i hear the "i sent it already" all the time...sure, you sent something but it isnt what was needed/requested.

    obviously, i can only assume things in your case. but, with what i have heard already, i am lead to believe that something is really missing.
    i wish you luck. i know it sucks when you get stuck in the loop and i most definately have an open mind this. but, i would also have to wonder what is really causing this to happen.

  • Sp
      18th of Jun, 2018
    0 Votes

    https://wordpress.com/posts/doctorsabusingtheirposition.wordpress.com
    this is my experience

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