Cigna Insurance Lifetime Max - Informed after the fact

[judychong]

Hi all, I'm kinda freaking out about a potential unexpected bill and hoping to get some advice.

TLDR: Wasn't aware of $10k lifetime max benefit for fertility costs even after tons of attempts to get clarity/inconsistent info from Cigna. Will I get slammed w/ a bill? Anything I can do to push back? (I live in NY if helpful.)

I just underwent my only egg freezing cycle a couple days ago at a clinic in NY. The process/doctors were great but throughout this process, my employer-provided health insurance (Cigna) was EXTREMELY confusing. I literally spent Nov. '23 through early Feb '24 trying to get clarification on whether elective egg freezing is covered—and sprang for higher cost insurance at end of 2023 even without that clarity.

Background: I work at a small non-profit that buys insurance with a bunch of other organizations. Our egg-freezing benefit is new/no one at my org had used it before. I made sure to confirm with our HR that elective egg freezing specifically (without proof of pre-existing infertility issues) is covered.

Even so, once I started looking into a clinic, I spent hours on the phone with Cigna after that where one rep would tell me that elective egg freezing was not covered under my plan and then when I would go back to my employer, they'd assure me that it was. Eventually Cigna higher-ups were able to confirm that the customer service reps were looking at an outdated 2023 plan, while the 2024 plan DOES cover elective egg freezing. I asked to see the 2024 plan to be able to read the language for myself but they told me that the plan wasn't available yet/was waiting on my employer (this was end of January already.) They wouldn't give me a timeline for when they would have it—but assured me I was covered.

This is something I was nervous about, so I flagged it for my clinic during my first appointment. They said they'd look into it and the financial coordinator even told me that if Cigna stated that I had coverage and then later revoked it, the clinic would eat the cost.

Ultimately, I got an email from the clinic saying that I was approved for coverage by Cigna, and that my out-of-pocket cost would be just $450 for anesthesia. I was thrilled. I also got automated phone calls from Cigna saying I was approved for the procedure + meds. (I still had the same issue with low-level Cigna reps saying I wasn't covered though when it came time to order meds through the pharmacy—but again was able to work it out.)

Throughout the process, I have not been paying co-pays or anything towards my $2+k deductible, which I was surprised about. I did have to pay about $130 when I ordered my meds.

Post-retrieval, the nurse asked me if I thought I might want to go for another cycle in the future. I told her I wasn't sure if my insurance would cover another cycle and she said she'd look into it. She got back to me today and said that my plan has a $10k lifetime max that was likely maxed out in this cycle. This was the first I'd heard of this.

Does this mean I'm going to be slammed with a bill for anything over that amount for the cycle I just did? I want to ask my clinic but wondering—is there any way I can push back given I was never notified/Cigna never provided language for my plan even after weeks of calls?

I'm happy to pay my $2+k deductible and any co-pays that apply, but feel really frustrated at the thought of having to pay potentially thousands more than that without having known that in advance. I don't have a big salary and the thought of a huge bill coming is stressing me out right as my hormone slump is starting.

 

[foreverthankful]

@judychong So a couple of things:

1. Just because a procedure receives prior authorization, it does not mean that insurance will cover the whole thing 100%. It just means that you meet the criteria for insurance to cover their portion in accordance to the contract/Summary Plan Description.
2. In this case, your Plan documents were not ready at the time of your procedure-- and that's pretty common across the board, most plan contracts are available about 90 days from the start of the plan. If you aren't sure how your plan will cover an elective procedure, always wait until you have it in writing in the plan documents.
3. If your plan has a 10K lifetime limit benefit, that's the most the plan is going to pay. You can appeal it, but this typically does not go in the member's favor. I can sympathize that you were not told there was a $10K lifetime limit, but that was more out of omission than anything else--- unless you asked "what are the benefit limits" and Cigna said their are no limits. Even still, the written contract is the prevailing document, even over what a rep tells you verbally. Unless you have it in writing from Cigna that they would cover everything 100% (not just that your prior authorization was approved), what a rep tells you does not trump what is written in your contract/plan document.

Now, just because your insurance may not cover anything over $10K, you also have the provider telling you that all you owe is $450 for the anesthesia. It's possible the provider will choose not to bill you for anything over your $10K benefit, and it sounds like they may have already kind of said that.

 

[judychong]

@foreverthankful Thank you so much for your response!! So frustrating that 90 days is common for this…I thought my experience was an anomaly. They don’t have a responsibility to provide the plan given I started paying for it January 1?

Is there anything you’d recommend I do now beyond just waiting for bills to arrive? I doubt my clinic won’t bill beyond the $10k…feeling a little hopeless :/

 

[judychong]

Also remembering now that I actually did email our employer's Cigna rep a bunch of times to ask if there were benefit limits among other questions. She never responded at all.

I think I probably asked over the phone too and was never told about this limit but that was verbal, not in-writing.