Ask a Business Lawyer. Get Business Law Questions Answered ASAP.
I believe this answers your question. However, if you need clarification or have follow-up questions regarding this matter, I will be happy to continue our conversation – simply reply to this answer. If you are otherwise satisfied with my response, please leave a positive rating as it is the only way I am able to get credit for my answers. Thank you, XXXXX XXXXX wish you all the best with this matter.
Hi, sent a long expert reply to you asking at what point all that Cigna does to disallow my treatments becomes fraud or what to call it.
As stated in more detail in my 3:30 reply, they have held my transferred and cashed electronic payments for which I had payment confirmation numbers from ADP (their COBRA billing company) and bank copies confirming they had the money for up to 3 months while telling me that was not proof of payment - internally they need their billing company (ADP) to force the records to them in their nightly download - it cleared my bank 7-28-13 and did not credit and reactive my coverage until 10-10-13. And the promised forced transfer took 7 instead of the promised 1 day, another 6 day delay.
They've delayed, required above and beyond repeated certifications and refused to acknowledge the validity of the prescriptions my doctors provided, claimed we had other insurance as confirmed by a secret confidential source we couldn't know about etc., to delay my care and save the cost of 5 treatment because they took so long to confirm coverage that they could no longer be scheduled. I'm to have one every 2 weeks and they turn it into one every 4 weeks by refusing to confirm coverage.
I've sent 4-7 hours 8 days in the last 2 weeks to get them to finally acknowledged they have been paid at least a month before it is due for the coverage thru December 1, 2013 and then found that they still reported that my coverage ended the end of July, the end of Aug to my care providers in Aug, Sept and October, thus saving them the cost of another treatment, delaying eye surgery and created a real billing mess with all of my providers.
When does this become fraud and are they in any way accountable for the damage created by the delays?
DISCLAIMER: Answers from Experts on JustAnswer are not substitutes for the advice of an attorney. JustAnswer is a public forum and questions and responses are not private or confidential or protected by the attorney-client privilege. The Expert above is not your attorney, and the response above is not legal advice. You should not read this response to propose specific action or address specific circumstances, but only to give you a sense of general principles of law that might affect the situation you describe. Application of these general principles to particular circumstances must be done by a lawyer who has spoken with you in confidence, learned all relevant information, and explored various options. Before acting on these general principles, you should hire a lawyer licensed to practice law in the jurisdiction to which your question pertains.
The responses above are from individual Experts, not JustAnswer. The site and services are provided “as is”. To view the verified credential of an Expert, click on the “Verified” symbol in the Expert’s profile. This site is not for emergency questions which should be directed immediately by telephone or in-person to qualified professionals. Please carefully read the Terms of Service (last updated February 8, 2012).