Plaintiff Claims Cigna Breached Insurance Policy by Denying to Cover Necessary Brain Surgery

Janet Roucis filed a lawsuit against Cigna Health Management, Inc. and Cigna Health and Life Insurance Company over claims that they breached the insurance policy they held with the plaintiff, acted in bad faith, and broke Colorado law when it did not cover the plaintiffs’ brain surgery. 

The lawsuit, which was filed last Friday in the Colorado District Court for the County of Denver, comes after Cigna repeatedly denied an insurance claim submitted by the plaintiff that encompassed her medically necessary brain surgery, the complaint explained.

The plaintiff applied for insurance coverage with Cigna through the use of an insurance broker in November of 2019. Cigna approved the application, and Roucis was then covered through an enforceable health insurance policy. The plan covers all services, treatments, and products that are deemed ‘medically necessary,’ which is further defined in the insurance policy. The insurance policy provides for “stent placement for idiopathic intracranial hypertension,” or IHH. Roucis claimed that she maintained the insurance policy by paying all monthly premiums and complying with other policy obligations.

In late August of 2020, the plaintiff had bilateral ear pain, sudden hearing loss, and a “severe decline in her quality of life,” due to a medical event that occurred in her inner ear. The event also caused the plaintiff to undergo “waves of excruciating and debilitating head and jaw pain due to intercranial pressure and tinnitus.” As a result of the pain, the plaintiff sought out Dr. Ian Kaminsky, a neurointerventional surgeon who is board certified in diagnostic radiology and neuroradiology. He determined that the best course of action was a cerebral angiogram, which he performed in late December of 2020.

The diagnostic procedure revealed that Roucis had a condition called idiopathic intracranial hypertension. The condition needed an urgent and necessary procedure to be resolved, which Kaminsky determined to be the “transcatheter placement of an intravascular stent.” Roucis needed to obtain pre-authorization from Cigna before having the surgery in order for it to be covered. Cigna denied her request for pre-authorization, citing that the surgery was not “medically necessary.”

Roucis appealed the decision, requesting an expedited appeal since her symptoms were severe and she had an urgent need for treatment. Cigna, however, refused to expedite the appeal. When the appeal hearing eventually took place on January 27th, 2021, Roucis and Kaminsky both attended, and Kaminsky explained how the surgery was medically necessary. Despite this, Cigna once again denied coverage.

Kaminsky performed the surgery on February 11th, 2021, and the plaintiff was forced to pay out-of-pocket for the surgery. The plaintiff maintained that in order to combat her severe symptoms, the surgery was medically necessary and that there is “no rational justification” for her insurance claim denial by the Defendant.

The denial purportedly caused Roucis to experience damages, injuries, and losses. The complaint cited claims for breach of contract, first-party bad faith, and violations of Colorado Revised Statutes 10-3-1115 and -1116. Due to the injuries the plaintiff has sustained, she is seeking both economic and non-economic damages, twice the covered benefit, litigation fees, pre and post-judgement interest, and any other relief deemed proper by the Court.