Cigna - Unethical and Uncool

We were not totally surprised to received Cigna's most recent letter informing us they have denied yet another (and final) of my disability benefit appeals. Although, I must admit I was allowing myself to dream of victory when their response was late (past the 45 day limit). I hoped perhaps the only way they would allow that occurrence would be in the case they needed to pay me money. Wrong again.

In the final appeal denial - all one and a half pages of it - they stated they had not received additional supporting evidence to prove that I am unable to work. Tim and I are wondering, then, what do they think of the 50 plus pages of information we sent?

I am including, below, the letter that Tim (mostly) wrote for our last appeal. I have removed certain information for either privacy or brevity. I am posting this online because I feel the Cigna contracted staff and doctors should be made accountable for their – what I believe to be – unethical actions and conduct.

____________________________________________________

Disability Management Solutions
CIGNA Group Insurance
12225 Greenville Ave., Ste. 1000
Dallas, TX 75243-9337

RE: Second appeal concerning termination of disability payments for
Judith Dodge Lowell

We are writing to appeal the decision by CIGNA to terminate disability benefits for Judi Lowell. This is our second appeal following termination. We also filed an earlier document arguing that termination should not proceed. Thus, in all, this is the third substantial document that we have submitted concerning this matter.

In April 2008, we requested and received from CIGNA what we understand to be the complete Administrative Record (AR) for Judi's case. Our appeal is based on material found in that Record. The AR contains a large number of documents, including notes from Judi's doctors, reviews by CIGNA's peer reviewers, and correspondence between Judi and CIGNA.

We would like to categorize our responses in five areas:

Qualifications and experience of CIGNA reviewers:

None of the review doctors appear to have any experience diagnosing or treating DID. We used internet resources to determine information about the doctors:

• We can find virtually no useful information on Dr. Unsell's medical expertise apart from his qualification in anesthesiology, and a statement that he specializes in addictions psychiatry. Dr. Unsell has no published papers listed in PubMed. In our internet research, we did find that Dr. Unsell's name has been published in the Park City Police Blotter for public drunkenness and assault of his wife. He has also been arrested for "Harassing Communications". Given that Judi's second husband is documented in the AR as being a substance abusing and abusive stalker, we believe that use of Dr. Unsell as a reviewer is not appropriate.
• Dr. DeFilippis is a clinical psychologist/neuropsychologist running a company providing various services, including forensic psychology. His web site lists the areas in which he has received post-graduate training - dissociation is not included. Although he has published a substantial number of papers, none of those listed on his web site address dissociation. A search on PubMed also failed to reveal any papers on dissociation.
• Dr. Shipko's web site says that he is a "board certified psychiatrist in private practice in Pasadena, CA. Known for his work in the field of psychosomatic medicine, his clinical subspecialty is panic disorder." Dr. Shipko has a strong media presence, and is evidently an expert in the connection between reflux and panic disorder. A search on PubMed failed to reveal any papers on dissociation.

We both have experience in searching for appropriate doctors. We would not choose any one of these doctors to treat Judi's illness. We do not understand why CIGNA regards these doctors as being suitable to provide a well-informed medical review of a patient with DID.

Failure to determine medical history and current status:

The AR clearly shows that CIGNA and the various review doctors have failed to take reasonable steps to determine Judi's medical history and current status. We highlight a few examples below:

• Neither of the three review doctors or anyone from CIGNA has talked directly to Judi.
• Neither of the three review doctors has talked directly to Judi's current doctor, Sybil J (or to any other of her previous providers). For example, in the section of Dr. Unsell's report entitled "Peer-to-Peer discussion", he mentions that he elected instead to send a questionnaire to Dr. J because of the "17 hour time difference", presumably not realizing that the time difference is actually 7 hours (a time difference cannot be greater than 12 hours). Dr. Unsell then bases his assessment on his uncertainty over questions that could (and should) have been discussed directly with Dr. J (for example, the form and severity of Judi's switching).
• Following her most severe episode, in 1998, Judi was admitted to Timberlawn hospital (http://www.timberlawn.com/trauma.htm) in Dallas, Texas for 14 days inpatient care, followed by 14 days outpatient. The treatment and hospital unit are specifically for patients with Dissociative Identity Disorder (DID/MPD). Timberlawn is operated by Dr. Colin Ross, one of the world's most recognized and respected experts in the field of DID. However, CIGNA has failed to obtain any documentation from Timberlawn. This is in direct contradiction to the letter of June 19, 2007 from CIGNA, which states that the review material includes "all the records from various hospitals and providers,..." We find this omission particularly strange since Timberlawn is located in Dallas, the same city as the corresponding CIGNA office. We find it even more troubling because Timberlawn is a leading center for the treatment of DID. Thus, for example, if as Dr. DeFilippis suggests, Judi is not actually DID or is malingering, the records from Timberlawn should show that. We note that the AR shows that CIGNA did ask Timberlawn for the records twice but then for some reason neglected to actually obtain the requested material.
• Judi was diagnosed as DID in 1997 by Dr. F, formerly of Albuquerque, New Mexico (as evidenced by two statements from Dr. F in the AR). Despite the obvious importance, Dr. F's case notes are not present in the AR.
• We have submitted two previous responses answering specific questions that were raised by CIGNA. We have not received any answers to the points addressed in these responses. In addition, the latest review, by Dr. Shipko, does not mention these as being amongst the documents that are being reviewed.
• As part of our second response, Dr. J (October 14, 2007) wrote a detailed explanation of why she considered Judi unable to work. The action sheet from CIGNA shows merely an annotation that "There is no new information that refutes the prior discussion re: functionality".
• At Dr. Shipko's request, Dr. J wrote another long, detailed letter to him (January 12, 2008) prior to his January 16 review. This letter is part of the AR but is not mentioned as one of the documents that Shipko reviewed, although he had specifically asked Dr.J for it. Since this letter addresses some of the issues in his review, this is a serious oversight that we believe undermines his review.

Errors, insufficient review of the AR, innuendo, and unfounded conclusions:

In addition, the reviews have errors, evidence of insufficient review of the AR, innuendo, and unfounded conclusions.

Examples from Dr. Unsell:

• Dr. Unsell writes, "If the Cx does indeed have DID, which is very rare, it would be common for her to be under the care of a mental health professional." The SIDRAN site (http://www.sidran.org) says that DID prevalence in the general population is about 1%. Judi's DID was diagnosed by Dr. F in 1997. Also, she is under the care of a mental health professional, Dr. J, who is experienced in treating DID.
• Following up on the previous point, we note that Dr. Unsell often uses the construction "If the Cx does indeed...", thus raising uncertainty and doubt without having to answer the implied question. He raises clearly important questions but does nothing to address them. Another example of this type of innuendo:
• "If the Cx indeed did write the blog, her psychiatric functional capacity may be significantly stronger than other sources indicate."
• Dr. Unsell wrote the following (obviously careless) statement: "She first saw the Cx on 10/25/05, and most recently saw the Cx on 10/18/05".
• Dr. Unsell wrote that the Cx has "patches of memory loss of traumatic childhood events." We presume he meant to write "recall" rather than "loss".

From Dr. DeFilippis:

• Dr. DeFilippis incorrectly refers to both F and D as "social workers". They are, in fact, MSW, Dr. F has a PhD in Education and they have many hours of continuing education credits from training opportunities in dissociation and trauma.
• Dr. DeFilippis consistently writes "D(removed for privacy)" instead of "D".
• Dr. DeFilippis writes "Unsel" instead of "Unsell".
• Dr. DeFilippis states that Judi's psychiatric history dates back to 1995 - in fact, it dates to the late 1980's.
• Dr. DeFilippis gives responses to two specific referral questions: on functional capability and on standard of care. His answer on functional capability relies upon his over-reading and misreading of our blog, and his answer on standard of care ignores much of the AR showing treatment by F, Timberlawn Trauma Unit, D, and J.

From Dr. Shipko:

• Dr. Shipko is clearly confused about the gender of Dr. Sybil J and even worse, refers to her as he and she in successive sentences. He is also mistaken about the gender of Dr Verna P, but he is consistent in mistaking her for him.
• Dr. Shipko writes Judi's name as "Judy", though the correct spelling is used throughout the AR.
• Dr. Shipko is asked by CIGNA to assess Judi's capability to work from July 19, 2007 - the date of the cessation of benefits. He actually has a lot of relevant information from Dr. J but he rejects this and instead, he draws an unfounded conclusion about Judi's state from the fact that Judi did not see Dr. J for a few months in mid 2007. Dr. Shipko deduces that the "most likely explanation for this attenuation of treatment, taken in conjunction with the other evidence of functionality, is that the claimant is significantly improved and back at her baseline of functionality when she was still working full-time." Dr. Shipko himself notes on page 5 that there was a similar gap in Judi's treatment from April 2004 to October 2004, yet does not draw the obvious but incorrect conclusion that she must have recovered then as well. As we have documented in our previous appeal, the reasons for the break in 2007 were financial, a desire to take a short break from the intense experience of therapy, and the fact that Dr. J was absent from work for some time with a broken shoulder.
• On page 8 of Dr. Shipko's report, he notes that Dr. J writes, "symptoms are anxiety, depression, mood changes, identity confusion, derealization, depersonalization, loss of time(s), social withdrawal and intrusive abdominal/pelvic discomfort". He also states that Dr. J "writes that the claimant is symptomatic on most days, is anxious and avoids socialization." However, in his conclusion, he baldly states that records do not reflect that either rapid switching or severe depression or anxiety are present. On page 12, Dr. Shipko states that "The information does not indicate that the claimant has a mood disturbance", in direct contradiction to his statement on page 8. The information available to him does indicate a mood disturbance, but in forming his conclusion he disregards the report of Dr. J, although Dr. J has treated Judi for three years and is best suited to provide a clinical report. Furthermore, only Dr. J has examined the patient, Judi, during the period in question - from July 19, 2007 onwards.

Our blog, http://tjoz.blogspot.com, is the focus of a lot of attention, both in the reviews and by CIGNA.

• In the letter of June 19, 2007, CIGNA relays a claim from Dr. DeFilippis that no alter has written in the blog. There is no explanation how this was determined. Dr. DeFilippis has not met Judi or any of her alters so we find it astonishing that he would make this claim.
• The hard copy of the blog in the AR contains handwritten comments of unknown origin. The comments extrapolate a lot from a little, always in a biased direction. For example, Judi wrote "Some friends told me about the blue ringed octopus...." and the note next to it read: "social?" Next to a note where Judi mentioned that she researched caravan parks on the internet, the note read "research and planning?" No notes were placed next to comments that indicated any problem with certain activities. There is no note next to where Judi talks about her depression or any mention of large gaps of time missing in the blog.
• About 80% of the blog posts were by Tim. Tim reads widely and often writes on the blog on a wide range of topics, and on books. Dr. DeFilippis comments that Judi is able to read complex books, such as by Cormac McCarthy, as evidenced by a blog entry. This is an unfounded supposition, which should have been checked - in fact, Judi has not read any substantial book in years, and that entry on the blog was written by Tim.

The blog is used by Dr. Shipko (letter to Dr. J, January 7, 2008) to argue that Judi is "capable of a high degree of socialization and activity". We found the following relevant entries for each month:

1. February 2005: 2 entries (trips to Santa Fe and Clovis - one night each)
2. April 2005: 1 entry (dinner at Epping with Indian friend)
3. May 2005: 1 entry (mention dog walks and meeting interesting people)
4. June 2005: 2 entries (re: Manly trip, Judi mentions socializing at the dog park daily)
5. July 2005: 2 entries (Berowra waters/Ferry trip with Tim, Juan and Rosa dinner)
6. August 2005: 1 entries (opera with Zoë)
7. October 2005: 2 entries (visit Michelle, Enno and Angelika for dinner)
8. December 2005: 3 entries (Ben and Katie, Visit with Bella and Lisa, Contemporary Museum visit, Ernie and Ruth visit)
9. April 2006: 1 entry (Judi describes people she has met on our street)
10. May 2006: 1 entry (museum trip - Tim and Judi)
11. June 2006: 2 entries (Manly Food and Wind, Urvashi and Watson's Bay)
12. December 2006: 1 entry (to see Priscilla, Queen of the Desert)
13. January 2007: 2 entries (Tim mentions Judi's birthday and lots of friends, and about Australia day with John and Alison)
14. February 2007: 1 entry (Judi mentions our caravan vacation)
15. March 2007: 1 entry (some "friends" told Judi about the octopus)

Thus in a period of over two years, the blog mentions 21 social events - less than one per month. We do not believe that any reasonable person would regard this as evidence of Judi's "high degree of socialization and activity".

Dismissal of Dr. J's qualifications and assessment:

Over the last three years, Dr. J has treated Judi regularly and is therefore in the best position to offer an assessment of her status and in particular Judi's ability to work. Faced with the clarity of Dr. J's submissions, all three reviewers have resorted to questioning her qualifications. We defer to Dr. J's most recent letter (see enclosed) for an account of her qualifications and experience. Clearly, she is both qualified and experienced at the appropriate level to treat and assess Judi's illness.

In support of Dr. J, we will relate how Judi came to choose Dr. J as her doctor. Before we came to Australia, Judi searched carefully for a suitable doctor, and ended up using the following approach - she contacted the International Society for the Study of Trauma and Dissociation (http://www.isst-d.org) and asked for a referral to a doctor capable of treating DID. The Australian contact for ISST-D, Dr. Francesca Collins, then suggested three names, including Dr. J Judi contacted Dr. J via email and, after some email discussion, Dr. J agreed to take Judi as a patient.

We strongly believe that Judi is receiving care of the highest quality from Dr. J. Her letters are part of the AR, and speak for themselves. We excerpt the conclusions from two of the letters:

January 12, 2008, to Dr. Shipko: "As an employer, I would love to employ people with Judi’s high level of intelligence and skill but I would not do so if the potential employee had such unpredictability and variable ability to cope with stress and normal tasks.

"I hope that my answers are clear and sufficient to convince you and the insurance company that she is unfit to hold regular employment and that furthermore, if she were to receive the payment which she believes she is entitled to receive, she will be in a better position to receive more intensive therapy and hopefully improve to the point of being able to resume gainful employment."

May 3, 2008, to CIGNA (attached): "I have no doubt that Judi would like to be gainfully employed, and I am hoping that this will happen in the foreseeable future. Meanwhile she is not currently fit to return to paid employment in any job where she would be required to attend consistently and reliably. Unless her disability payment is reinstated by Cigna, I believe that the company’s action is a revictimisation of an already greatly traumatised woman."

Failure of attempts to understand CIGNA procedures:

We have also attempted to ascertain whether CIGNA staff followed CIGNA policies in reviewing Judi's case - for example, are the reviewers themselves selected on the basis of expertise relevant to the case at hand? Are the reviewers vetted in any way - why was Dr. Unsell's arrest record not a disqualification? Why was Dr. Shipko only asked to review Judi's ability to work from the date of termination of benefits? None of the doctors talked to Judi or her current doctor – is this consistent with CIGNA procedures?

Accordingly, Judi wrote to Kim Jackson, asking for the relevant manual, evidently called "The Book of Operating Knowledge".

From: Judi Lowell [mailto:judi.lowell@gmail.com]
Sent: Sunday, May 11, 2008 8:21 PM
To: Jackson, Kathryn I 212
Cc: Cornwell Tim; Lowell Judi
Subject: "The Book of Operating Knowledge"

Dear Kim,

Below is the complete text of an email I sent to you on April 18, 2008.
Apparently, the last part of the message was deleted when I sent it via pdf.

The deleted section is:

Does Cigna have a list or document that claim reviewers refer to that contains
this type of information? May I have a copy? Is there any other information
and/or document(s) that Cigna uses as reference for claim reviewers that is
relevant to my case? May I have a copy?

Thank you for your time and attention.
Best Regards,
Judi Lowell

As we are continuing to work on our appeal, I would like to go forward with
our request for this information, and I understand the manual I refer to is
called "The Book of Operating Knowledge." As I just recently found my error of
omission, and we are anxious to complete this step of the appeal process, I
would appreciate it if you could send the book to me as soon as possible.

Thank you in advance for your assistance.

Judi Lowell

Ms. Jackson replied that the internal guidelines are proprietary information:

Received: May 13, 2008 6:17 AM ChST
Expires: Jul 12, 2008 6:17 AM ChST
From: Jackson, Kathryn I 212
To: judi.lowell@gmail.com
Subject: RE: "The Book of Operating Knowledge"

Ms. Lowell,

Internal guidelines are proprietary information. Each claim is reviewed and
evaluated individually and a determination is made based upon the medical
documentation and the policy under which the employee was covered.

Based on this information, we are unable to provide you with a copy of what
you are referring the Book of Operating Knowledge. If you need anything else,
please let me know.

Thanks,

Kim Jackson
Case Manager
Dallas Claims Office
(800) 352-0611 ext. 5692
Fax 860-731-3493

Confidential, unpublished property of CIGNA. Do not duplicate or distribute.
Use and distribution limited solely to authorized personnel. ? Copyright 2008
CIGNA


We found this hard to understand - the policy is not specific about the procedures to be followed in claims dispute. We also found a relevant court case that seemed to indicate that CIGNA must release such documents (quoted in the letter). On May 12, 2008, Judi wrote to Kim Jackson, quoting a specific web site:

From: Judi Lowell [mailto:judi.lowell@gmail.com]
Sent: Monday, May 12, 2008 5:06 PM
To: Jackson, Kathryn I 212
Cc: Cornwell Tim; Lowell Judi
Subject: Book of Knowledge

Kim,

You mention that this book is proprietary information, but I found the following on a lawyer's blog online. Has that ruling been overturned? I'll write to the Law firm as well to ask them to confirm their information.

Thank you for your speedy response,

Judi Lowell


http://www.longtermdisabilitylawblog.com/benefit_denials/

CIGNA's Claims Manual is Not Confidential

If CIGNA, or one of its subsidiaries, denies your long term disability claim, you should send a request to CIGNA demanding a copy of its claims manual. You should ask for it by name; CIGNA calls its claims manual "The Book of Operating Knowledge."

On November 14, 2006, we successfully defeated CIGNA's attempt to prevent disclosure of its Book of Operating Knowledge. In the case of Levy v. INA Life Ins. Co. of New York, 2006 U.S. Dist. LEXIS 83060 (S.D.N.Y. Nov. 14, 2006), Judge Gerard E. Lynch denied CIGNA's motion. Judge Lynch explains:

The case for non-disclosure is further undermined by Department of Labor regulations requiring disclosure of procedures employed during claims processing as mandated under section 503 of ERISA. See 29 C.F.R. § § 2560.503-1(g)(1), (h)(2), (i)(5), (j)(5), and (m)(8). Indeed, the Department of Labor "has taken the position that internal rules, guidelines, protocols, or similar criteria would constitute instruments under which a plan is established or operated within the meaning of section 104(b)(4) of ERISA and, as such, must be disclosed to participants and beneficiaries." U.S. Department of Labor, "Frequently Asked Questions about the Benefit Claims Procedure Regulation," C-17, http://www.dol.gov/ebsa/FAQs/faq_claims_proc_reg.html. These requirements make plain that such claims-handling manuals, whether in whole or piecemeal, are likely to be disseminated widely to plan participants and to litigants challenging benefits denials. Under these circumstances, the effort to protect such materials as confidential is quixotic.


Ms Jackson replied with an even less helpful and intelligible response:

From: "Jackson, Kathryn I 212"
Date: 15 May 2008 5:20:30 AM
To: "Judi Lowell"
Subject: RE: Book of Knowledge

Ms. Lowell,

Sorry it has taken me a few days to get back with you, but I needed to clarify with my boss on how to respond. Please see below.

Our decision utilized the information contained in the file, together with the policy. We did not rely on any procedures contained in the Book of Knowledge in making a determination on your claim. Furthermore, this request is unclear and not specifically related to the decision rendered in your claim.

Thank you,

Kim Jackson
Case Manager
Dallas Claims Office
(800) 352-0611 ext. 5692
Fax 860-731-3493

Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © Copyright 2008 CIGNA

We then made one final attempt:

From: judi.lowell@gmail.com
Subject: Request for Book of Operating Knowledge
Date: 21 May 2008 1:15:21 PM
To: Kim.Jackson2@cigna.com
Cc: timcornwell@gmail.com, judi.lowell@gmail.com

Hi Kim,

I just want to clarify my previous request, since your boss mentioned that it was unclear. I might have referred to the book in question as the "Book of Knowledge". However, the law firm referred to it as "The Book of Operating Knowledge." If I was unclear or incorrect about the complete title, it was also mentioned as "The Book of Operating Knowledge" in the excerpt from the Law Firm blog which was included in the same email message to you.

However, I'm certain that your boss would understand these two titles as referring to the same book of reference used by Cigna, but just in case, I wanted to provide this clarification.

I also wrote the following, which seems quite clear as to what I was indeed asking for:

Does Cigna have a list or document that claim reviewers refer to that contains
this type of information? May I have a copy? Is there any other information
and/or document(s) that Cigna uses as reference for claim reviewers that is
relevant to my case? May I have a copy?

So I guess I am asking for any manuals or documents that contain procedures that Cigna follows to ensure consistent levels of standard in their review procedures. I found very little of that type of guidance in the policy.

In addition, I found the following in the DOL.gov link provided by the law firm blog:

The regulation requires that a claimant, have access to, and copies of, documents, records and other information relevant to the claimant's claim. For this purpose, the regulation defines as relevant any document, record, or other information that:

* Was relied upon in making the benefit determination
* Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether it was relied upon
* Demonstrates compliance with the plan's administrative processes and safeguards for ensuring consistent decision making
* Constitutes a statement of policy or guidance with respect to the group health plan concerning the denied treatment option or benefit for the claimant's diagnosis, without regard to whether it was relied upon in making the benefit determination. See §§ 2560.503-1(h)(2)(iii) and 2560.503-1(m)(8)

Any explanation and/or documents you can provide us would be helpful.

Best Regards,
Judi Lowell

With the following reply:

From: "Jackson, Kathryn I 212"
Date: 21 May 2008 10:50:30 PM
To: "Judi Lowell"
Subject: RE: Request for Book of Operating Knowledge

Ms. Lowell,

Please be advised again that the determination was based on the documents contained in your file, which a copy was mailed to you on or around 3/19/08. We did not utilize the Book of Knowledge to make a determination in your claim.

Thanks,

Kim Jackson 
Case Manager 
Dallas Claims Office 
(800) 352-0611 ext. 5692 
Fax 860-731-3493

In pursuing our request, we were guided by material on the website of the Employee Benefits Security Administration (http://www.dol.gov/ebsa). The reason for our request was to understand the procedures followed by CIGNA in determining Judi’s case since the procedural documentation in the AR is minimal. CIGNA has replied multiple times that the determination was based on the documentation in the AR – which is not at dispute. At the end of this exchange, we were unable to decide whether CIGNA was being obtuse or obstructive. The result is the same: we were not able to determine the procedures used by CIGNA in this case.

SUMMARY:

The evidence above shows that:

1. The CIGNA reviewers are poorly suited to review Judi's status,
2. Both CIGNA and the reviewers failed to take reasonable steps to determine Judi's medical history and current status,
3. The reviews have careless errors, evidence of insufficient review of the AR, innuendo, one-sided reading of the evidence, and unwarranted conclusions,
4. The qualifications of Dr. J are incorrectly dismissed as being insufficient, and her assessment of Judi as being unable to work is therefore erroneously rejected.
5. CIGNA rebuffed our efforts to understand the procedures followed in Judi's case.

Thus, we have shown that CIGNA has failed to give Judi's case a full and fair review. The conclusion by CIGNA that Judi is now able to work is therefore unfounded, and in particular is not supported by an impartial reading of the full material in the AR.

Although we contend that the material in the AR when read impartially will support our case that Judi is not able to work at this time, we include the following additional material:

• The most recent letter from Dr. J to CIGNA,
• A personal statement from Tim concerning Judi (dated May 11, 2008),
• A personal statement from Judi regarding her condition and symptoms,
• Entries from Judi's diary.

The letter from Dr. J provides highly specific information on Judi's case.

CIGNA has told us previously that it will not use the personal material, such as that from Tim and Judi, in the review process. Nevertheless, we ask that it be placed in the AR. If this appeal is rejected, we will proceed to our next level of remedy.

This letter was written by Tim, with comments and minor revisions by Judi.

Sincerely,

Judi Lowell
Tim Cornwell
May 24, 2008