Cigna Faces Class-action Over Coverage Denials by AI Claims System

Cigna is facing a class-action lawsuit that accuses the company of employing an algorithm to review and reject hundreds of thousands of patient health insurance claims, with minimal individual doctor oversight. The lawsuit, filed in the U.S. District Court in Sacramento, claims that Cigna’s practices violate California state law, which mandates insurers to conduct a thorough, fair, and objective investigation into each patient claim.

The crux of the issue lies in an algorithm known as PxDx, which the lawsuit alleges Cigna is utilizing to deny claims, ultimately saving the company money. The deployment of algorithms and artificial intelligence to replace human workers in various capacities is becoming increasingly prevalent.

Among the plaintiffs is Suzanne Kisting-Leung. After undergoing an ultrasound ordered by her doctor to investigate concerns about ovarian cancer, Cigna denied her claim for the ultrasound and a subsequent procedure. The insurer asserted that neither of the procedures was medically necessary, leaving Kisting-Leung with a hefty bill.

A recent report by Propublica revealed that over a two-month period last year, Cigna denied more than 300,000 claims, averaging a mere 1.2 seconds spent on each. Doctors did not review the medical records before rejecting the claims, raising questions about the algorithm’s accuracy and fairness.

The lawsuit aims to shed light on the potential ramifications of an overreliance on algorithms in the healthcare industry, especially when it comes to crucial medical insurance claims. The case may serve as a pivotal moment in determining the proper balance between human oversight and algorithmic decision-making in health insurance processes.