Insurance giant reverses position, now pays claim

But for more than a year, Cigna, one of the country’s largest insurers, refused to pay, saying Cregg, who was 66 when he had the surgery, should have taken Part B of Medicare. Instead of risking a ruined loan, Cregg paid the bills from his medical providers.

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

The column drew widespread attention, with nearly 300 readers posting comments on the online version, which was posted under the caption, “Don’t make the Medicare mistake this couple made. It cost her a lot.”

On Tuesday, the day after the column appeared, Cregg received a call from Cigna saying that the cost of his arthroscopic surgery would be covered after all, Cregg said.

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

“I’m thrilled to finally find a proper solution to this mess,” Cregg said in an interview after the call. “Cigna was wrong from the start. I tried different ways to solve it but Cigna just ignored me.”

The ordeal took a toll on Cregg. In a letter to Cigna he wrote: “This situation is ruining every day and causing great concern to me and my family. My being in this situation is not right, not fair, not legal. I would really appreciate it if Cigna would do the right thing, pay the outstanding debt and let me get on with my life.”

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

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One of those documents was a letter from Cigna to Cregg that said, “After reviewing your medical information and health plan, we agree [the surgery].”

Many readers who have posted comments on the column have expressed their sympathy and confusion about the health insurance system to Cregg.

“[Cregg] have written documentation from Cigna approving the process. How can Cigna say ‘We made a mistake’ and not pay?” asked one reader.

“Bingo,” replied another reader. “If there was permission, then Cigna does something [it does] best: give up.”

“I think it’s a shame that Medicare [is] it’s complicated and hard to understand,” said another reader.

Here’s what happened:

Cregg turned 65 in 2020 but did not sign up for Part B, which covers doctor appointments and outpatient care. Everyone should sign up at 65 (or face later penalties), but there’s one 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 a non-governmental technology company. Bethann’s former employer offered the couple insurance coverage under a law known as COBRA, which requires most employers to continue to offer terminated employees group insurance for at least 18 months.

Because Bethann was too young to take Medicare, the Creggs chose COBRA with assurances that they had all the benefits and rights of active employees. What the Creggs didn’t realize was that under Medicare rules, a COBRA plan did not equate to an active employee.

In fact, Medicare allows the exception for enrollment 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 are not working, such as B. Those covered by COBRA.

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Cregg said someone should have specifically told him not to attend COBRA and instead enroll in Medicare Part B. Instead, he said he had been misled into believing his status had not changed under COBRA.

The seven-page, one-line letter the Creggs received informing them of their COBRA rights states that terminated employees and their dependents at COBRA “will have the same rights under the [Cigna] plan like other participants” in the plan.

Cigna did not respond to questions Wednesday, but released this statement: “While we are not able to speak to an individual customer’s case, we encourage customers to consult their coverage records, contact their insurance provider or COBRA administrator turn around. and work with your doctor to review coverage and any restrictions prior to scheduled treatment.”

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

Have a problem? Submit your consumer edition to [email protected] Follow him on Twitter @spmurphyboston.

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