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THE FINE PRINT

Insurance giant Cigna reverses position, will now pay claim

Pedestrians walked towards Cigna Corp. headquarters in Bloomfield, Conn.Michael Nagle/Photographer: Michael Nagle/Bloo

A year after he grudgingly paid $20,000 out of pocket for knee surgery, Alan Cregg will finally be reimbursed that amount by his former health insurance company.

Cregg long disputed the insurance company’s refusal to pay his claim, pointing out that his surgery had been approved in advance by the insurer in writing.

But for more than a year, Cigna, one of the country’s largest insurers, refused to pay, saying Cregg, 66 years old when he had the surgery, should have been on Medicare Part B. Rather than risk ruined credit, Cregg paid the bills from his medical providers.

Cregg’s plight was featured in the Globe’s The Fine Print column on Monday. The column focused on the lack of clear communication regarding Cregg’s obligation to go on Medicare.

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The column gained wide attention, with almost 300 readers posting comments to the online version, which was published under the headline, “Don’t make the Medicare mistake that this couple made. It cost them dearly.”

On Tuesday, one day after the column appeared, Cregg got a telephone call from Cigna saying it would cover the cost of his arthroscopic surgery after all, Cregg said.

Cregg said Cigna told him it would pay his medical providers and they would then reimburse him.

“I’m thrilled to finally get a proper resolution to this mess,” Cregg said in an interview after the call. “Cigna was wrong from the beginning. I tried several avenues to get it resolved but Cigna just ignored me.”

The ordeal took a toll on Cregg. In one letter to Cigna, he wrote, “This situation ruins every day and causes me and my family great anxiety. My being in this situation isn’t right, isn’t fair, isn’t legal. I would very much appreciate Cigna doing the right thing, paying the outstanding claim, and letting me go on with my life.”

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In frustration, Cregg last month turned to the Globe for help. Cigna, however, declined to respond directly to the Globe’s detailed questions, which were sent to it along with copies of documents provided by Cregg prior to publication.

One of those documents was a letter from Cigna to Cregg saying “after reviewing your medical information and health plan, we approve [the surgery].”

Many readers who posted comments to the column expressed sympathy to Cregg and bewilderment about the health insurance system.

“[Cregg] had written documentation from Cigna authorizing the procedure. How can Cigna say ‘we made a mistake’ and not pay?” asked one reader.

“Bingo,” another reader responded. “If there was an approval, then Cigna is doing what [it does] best: Reneging.”

“I think it is disgraceful that Medicare [is] this complicated and hard to understand,” said another reader.

Here’s what happened:

Cregg turned 65 in 2020, but didn’t sign up for Part B, which covers doctor appointments and outpatient care. Everyone is supposed to sign up at 65 (or face later penalties), but there is an exception that applied to Cregg: He was still under the Cigna insurance plan his wife had at work.

But about a year later, his wife, Bethann, was fired from her job at an out-of-state tech company. Bethann’s former employer offered the couple coverage under a law known as COBRA, which requires most employers to continue to offer group insurance to terminated employees for at least 18 months.

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With Bethann too young to go on Medicare, the Creggs opted for COBRA, with assurances they had all the benefits and rights of active employees. What the Creggs didn’t realize was that, under Medicare rules, being on a COBRA plan wasn’t the equivalent of being an active employee.

In fact, Medicare allows for the exception for signup at age 65 and older only for those who have employer-sponsored insurance and are still working, not for those who have employer-sponsored insurance but aren’t working, such as those covered by COBRA.

Cregg said someone should have explicitly told him not to go on COBRA but to sign up for Medicare Part B. Instead, he said he was led to believe there was no change in his status under COBRA.

The seven-page, single-spaced letter the Creggs received informing them of their COBRA rights said terminated employees and their dependents on COBRA “will have the same rights under the [Cigna] plan as other participants” in the plan.

Cigna did not respond to questions on Wednesday but it did release this statement: “While we’re unable to speak to the case of any individual customer, we encourage customers to consult their coverage documents, reach out to their insurance provider or COBRA administrator, and work with their doctor to verify coverage and any limitations prior to scheduled care.”

Anyone who needs help navigating the Medicare system can get it free from the Shine program through their local senior center.


Got a problem? Send your consumer issue to sean.murphy@globe.com. Follow him on Twitter @spmurphyboston.