Cigna – Lawsuit?

TDLR: Cigna denied a surgical procedure and an appeal. A third party overturned that decision and although this was ‘final and binging’, instead of paying, Cigna is being unreasonable.

I had surgery last year. Dispite my doctor and previous doctors stating it was medically necessary, Cigna denied it. I appealed and the appeal and review took 17 days longer than the timeframe Cigna promised.

During this time (since it took so long) I had the surgery performed, and paid ~$10k out of pocket. After the surgery, I got the second denial. It may be relevant to note that the inital denial was pretty clearly rubber-stamped and adding insult, it was denied by Cigna’s director of Pediatrics. This procedure is female specific and well outside of a pediatrician’s purview. It is well known that Cigna used their PXDX system to deny claims within 1.5 seconds without the doctors actually reviewing anything (and this is a class action status at this point I believe).

We appealed the denial and when the appeal was also denied, we used the final option of using Cigna’s external review which is final and binding (paid for by Cigna). That review resulted in reversing Cigna’s decision and making the surgery covered.

Cigna of course acknowledges this and stated they will pay and it is now covered, I just need to “submit the paperwork.” This was back in March of this year.

I’ve filed all paperwork they asked for, except a superbill which we did not get because insurance wasn’t paying at the time of the procedure . The Dr and facility will not provide one as it is seen as unethical and possibly illegal for a past procedure.

I’ve sent Cigna invoices and official bills that were paid from the doctor and surgery center. Then they asked for procedure codes, NPI numbers, etc., all of which I’ve provided. It’s been seven months and they haven’t paid citing “missing paperwork and a lack of a superbill”. At what point does this become a lawsuit and/or Bad Faith by the insurance company suit? I’m in TX and my understanding is that the bad faith insurance laws are not great. thank you for any advice on how to hold Cigna accountable and get reimbursement for the procedure.

Edited to add that this is a “really good” OAP Cigna plan through my employer.