2023 Sports, Health and Wellness, Small/Medium Newsroom finalist

Uncovered: How the Insurance Industry Denies Coverage to Patients

About the Project

More than 200 million Americans are covered by private health insurance. But that doesn’t mean they get the care they need when illness strikes.

In “Uncovered,” ProPublica and The Capitol Forum exposed the inner workings of health insurers in denying care to the people covered by their plans.

Big insurers employ doctors, called medical directors, who have sweeping power to approve or reject requests to pay for all kinds of critical care – from life-saving drugs to complex surgeries. They do so by substituting their judgment for those of treating physicians, often ruling that requested care is not “medically necessary.”

ProPublica and The Capitol Forum obtained internal documents, audio recordings, emails, physician reports and other records to show how decisions by insurance company medical directors are often made with little or no review of patient records or any consideration of a treating doctor’s recommendations.

The publications revealed how the insurer Cigna built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file, leaving people with unexpected bills. Over a period of two months, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case.

To understand the impact that denials have on patients, we set up an interactive webpage that allowed people to share their experiences with us. We received more than 1,850 submissions.

That led us to investigate the case of Christopher McNaughton, a Penn State University student with a life-threatening case of ulcerative colitis. McNaughton’s care, a regimen of biologic drugs, was expensive.

Behind the scenes, the insurer United calculated how much it would save if it changed his treatment to a cheaper one that McNaughton’s doctor said had already failed and would put his patient’s life at risk.

A doctor hired by United to review the case warned that denying payments for McNaughton’s treatment could put his health at risk, but the company buried his report and did not consider its findings. The insurer did, however, consider a report submitted by one of its own medical directors who admitted he gave “zero weight” to the treating doctor’s opinion and simply rubber-stamped the recommendation of a United nurse to reject paying for the treatment.

United officials laughed when discussing a decision to reject McNaughton’s treatment, with one saying any appeal by the student would be “a waste of money and time” because “we’re gonna get the same answer.”

McNaughton was a rare case. Few people appeal denials of care.

McNaughton filed a lawsuit and eventually got United to agree to pay for this treatment. But it came at a cost that was chronicled in our story. The stress of the fight triggered physical symptoms and he considered suicide. All in an effort to get United to keep paying for a treatment that saved his life.