back to article Cigna sued for using software to deny healthcare insurance claims

Cigna has been sued in California based on allegations the US healthcare insurer unlawfully reviewed insurance claims using automated systems rather than relying on humans. Under America's healthcare system, such as it is, a medical patient typically sees a doctor and receives diagnosis and possibly treatment. The physician ( …

  1. Claverhouse Silver badge


    "Based on our initial research, we cannot confirm that these individuals were impacted by PxDx at all."

    Before issuing that statement, wouldn't it be better to look into each of these two 'individuals' files and so be able to flatly deny, rather than be 'unable to confirm' ?

    1. Anonymous Coward
      Anonymous Coward

      Re: Breakdown

      What, you think Cigna write down anything that could possibly be used against them? And then put that into the individuals' files where it could easily be found?

      What are you, some kind of commie?

      This is Business In 'Murica just Doing Its Thing.

    2. Anonymous Coward
      Anonymous Coward

      Re: Breakdown

      That would definitely be prohibitted by HIPAA.

      The attorney is bullshitting and CIGNA are lying.

  2. Anonymous Coward
    Anonymous Coward

    If Cigna's statement is accurate...

    All they did was auto-approve some standard claims if they matched certain specific parameters, while reviewing (NOT auto-denying) the ones that didn't. I have no love for Cigna or other insurance companies, having spent far too many hours getting claims fixed (i.e. reprocessed after being wrongly denied), but in this narrow case they seem to be doing things reasonably.

    Now, that statement about "nobody was denied service because our claims processing is after the fact" is sophistry. If you're denied for a claim, you owe the doctor whatever they feel like charging you, and you won't be going back because of the cost. That's still effectively denying service.

  3. that one in the corner Silver badge

    I hope we all felt that one in our guts

    > simple sorting technology that has been used for more than a decade – it matches up codes, and does not involve algorithms


    But then I read on:

    > perhaps not what people in general think when they hear the word "algorithm" in this era of machine learning and recommendation engines.

    Recommendation engines - those simple sorting routines that literally come up with "people who bought secateurs also bought bandages"!

    Five years after Hannah Fry's book, it looked like Joe Public was understanding the word. Now some prat of a lawyer is trying to argue against its meaning. Aaaarghhh.

    What cruel god is this, that plays with us so?

    1. Paul Herber Silver badge

      Re: I hope we all felt that one in our guts

      'What cruel god is this, that plays with us so?'

      The US dollar.

      1. Anonymous Coward
        Anonymous Coward

        Re: I hope we all felt that one in our guts

        The Free Market.

  4. Richard 12 Silver badge

    So what is the computer doing then?

    Cigna claims to be using an "expert system" algorithm, while also saying that's not an algorithm?

    The judge needs to hold that legal firm in contempt for deliberately lying in official submissions to the Court.

  5. Zippy´s Sausage Factory

    And yet many Americans still think a universal taxpayer-supported healthcare system is the work of the devil. I don't understand it myself.

    1. IGotOut Silver badge

      Propaganda, my dear friend, years and years of corporate propaganda and government backhanders

      It's the same reason the labour laws are so poor and why customers still have to pay their waiter / waiters wages

      1. Anonymous Coward
        Anonymous Coward

        I don't want to pay for your bad habits, or if you don't have any, for your neighbor's bad habits. I've spent less than $500 on insurance and medical expenses in the last 23 years.

        1. Anonymous Coward
          Anonymous Coward

          I'm pretty sure that my preschooler having to go to the hospital because of a lack of ability to breathe decently doesn't have anything to do with my or my neighbors' bad habits. (No smokers in the house, and outside air is quite clean.)

          Sometimes medical events happen without anyone being at fault.

        2. Anonymous Coward
          Anonymous Coward

          The word "society" means nothing to you at all, does it? Have a hint: this is how you spell "civilisation".

        3. Anonymous Coward
          Anonymous Coward

          The really sad thing about this reply is the inability to look ahead[1] - and consider how insurance basically works (well, how it was supposed to work before actuaries got too involved ...) and how that compares to how a funded medical system actually works.

          The being a total dick and blaming other people for *all* of their medical problems is just the icing on the cake that makes you a fully rounded personality.

          [1] wait until you see your insurance premiums as you age and/or develop an unfortunate condition of your own.

  6. Jonathon Green


    “You keep using that word. I do not think it means what you think it means…”

    1. KarMann Silver badge

      Re: “Algorithm!”

      So, it's not about a certain former Vice President's dance moves??

  7. Mike 137 Silver badge

    "does not involve algorithms"

    Every functional piece of code consists of implementation of one or more algorithms, so software that "does not involve algorithms" can not exist. The origin of this error is the same sloppy thinking that has restricted "crypto" to the sole meaning of cryptocurrencies. If this process of verbal reductionism persists, eventually we won't be able to discuss anything except the latest technological flummeries.

    1. katrinab Silver badge

      Re: "does not involve algorithms"


      def ApproveClaim(claimdetails):


      is an algorithm.

      I'm not sure what language the code is written in, but I think that is pretty much what it looks like.

      1. el_oscuro

        Re: "does not involve algorithms"

        That would be too obvious, and might be too much for our bought and paid for politicians to not do something about. I figure it is something more like:



        if [ $((1 + $RANDOM % 100)) -gt 70 ]; then






        BTW, I am a "customer" of Cigna and my healthcare is a clusterfuck, Everything about this is true.

  8. martinusher Silver badge

    Not quite right

    Under our system a doctor will diagnose a condition and recommend a treatment. The insurance company then has to preapprove the recommendation. Its this step that's prone to automatic denial. If you go to treatment without permission then the insurer won't pay for it.

    I think that you're suffering the same process in the UK, the difference being that the applications get lost in some bureaucratic maze rather than being outright denied.

    1. Michael Wojcik Silver badge

      Re: Not quite right

      I've had US health care my entire life, under various types of plans – "conventional" (which isn't anymore, and hasn't been for a while), HMO, PPO ... – and none of them have worked the way you describe. With HMOs it is often required to get a referral for out-of-network non-emergency care. All the PPOs I've had have approved payment after treatment, not before; there hasn't been any pre-approvement process.

      1. Anonymous Coward
        Anonymous Coward

        Re: Not quite right

        I've had US health care all my life, too. Lots of stuff requires preauthorization. What's really confusing is sometimes the preauthorization is needed for emergency care, so the preauth is done after the care is administered. (I swear I am not making that up!)

        1. Anonymous Coward
          Anonymous Coward

          Re: Not quite right

          "sometimes the preauthorization is needed for emergency care"

          It is therefore vitally important to have your insurance details on the lock screen of your phone (and on speed dial if you are lucky enough to catch you before the timeout licks the phone).

          Dystopia? No, dat 'topia, dis topiary.

          1. Anonymous Coward
            Anonymous Coward

            Re: Not quite right

            (The AC you replied to)

            They administered the emergency care well before asking for insurance. The care had to be “preauthorized”, which in medical jargon (doublespeak?) means the physician has to provide documentation showing why the care is medically necessary, before the insurance will cover it. Being emergency care, the “preauthorization” was performed after the care was administered, weeks later, in fact, even after the claim was “denied”. (Another bit of doublespeak, in many cases “denied” just means “we want some info first”.)

  9. MJI Silver badge

    Very weird

    I just get go to doctors, or get sent to hospital.

    Had in last year MRI, CT, XRays, lots of blood tests, lots of doctors visits, ultrasound.

    Not a hint of insurance questions.

    Except told that if I drove my licence and car insurance would be invalid.

    1. decentralised

      Re: Very weird

      "Except told that if I drove my licence and car insurance would be invalid."

      Sorry. That's a hard thing to deal with. Hope you have the help you need.

      1. MJI Silver badge

        Re: Very weird

        Was 3 or 4 days then they decided not a TIA so could drive.

        Still being investigated and that was 7 months ago.

      2. MJI Silver badge

        Re: Very weird

        MRI was no fault found!!!!

  10. David Nash Silver badge

    Unchecked algorithm?

    Not according to this quote: "If there is not a match, the claim goes to one of our board-certified medical directors for review"

    That doesn't sound "unchecked" at all, in fact doesn't "for review" explicitly state that the claim is being checked?

    1. Michael Wojcik Silver badge

      Re: Unchecked algorithm?

      That's what Cigna claim. The plaintiffs claim otherwise.

  11. xyz123 Silver badge

    CIGNX denies claims based on if they think the patient is "too old to live" or has a likelihood of becoming MORE ill and thus making more claims. Deny claim, wait for grandma to snuff it and go quiet, hoping no-one realizes she was insured and the medication would have prolonged or saved her life.

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