Facts

Lipedeman is a rare condition involving an abnormal buildup of adipose tissue, usually in the lower body, that is chronic, progressive, painful, and immobilizing. It is estimated that lipedema affects nearly 11% of the adult female population. The only effective treatment for the side effects of lipedema is a specialized form of liposuction. Meanwhile, Cigna Corporation and Cigna Health and Life Insurance Company insures and administers health insurance plans. Cigna plans exclude from coverage medical services that Cigna considers "experimental, investigational or unproven," including liposuction for the treatment of lipedema under Medical Coverage Policy No. 0531. Banafsheh Akhlaghi was diagnosed with Stage 3 lipedema, which caused her pain, immobility, and other problems. She was covered under an ERISA health plan through her employer. After her physician submitted information to Cigna setting forth her diagnosis and proposed treatment, Akhlaghi requested that Cigna provide coverage for specialized liposuction to treat her lipedema. On April 15, 2019, Cigna sent a written communication to Akhlaghi and her physician denying coverage for the proposed surgery, citing Medical Coverage Policy No. 0531. Akhlaghi appealed but Cigna denied the appeal on June 12, 2019. On June 27, 2019, Akhlaghi, on behalf of herself and all others similarly situated, brought an action against Cigna Corporation and Cigna Health and Life Insurance Company, alleging unlawful denial of plan benefits. The class included all person covered under ERISA health plans, self-funded or fully insured that were administered by Cigna and whose claims for specialized liposuction for treatment of their lipedema were denied as "experimental, investigational, or unproven." On June 15, 2021, Cigna revised Medical Coverage Policy No. 0531 to remove its coverage statement that Lipedema surgery was "experimental, investigational, or unproven" and instead stated that it was considered medically necessary when certain criteria are met.

PLAINTIFF'S CONTENTIONS: Plaintiff alleged that defendant followed a practice of denying claims for specialized liposuction for the treatment of lipedema on the basis the treatment is "experimental, investigational, or unproven" pursuant to Medical Coverage Policy No. 0531, even though liposuction is the only therapy available for this condition and has been shown to have beneficial effects from various studies. As such, plaintiff argued that defendant improperly denied plaintiff and the class members claims for liposuction treatment in breach of its fiduciary duties.

DEFENDANTS' CONTENTIONS: Defendants denied all contentions.

Result

The parties reached a settlement in which Cigna agreed that all class members who paid out-of-pocket for liposuction to treat lipedema can make reimbursement claims. Cigna also agreed not to change its revised position that liposuction to treat lipedema is not "experimental, investigational, or unproven" unless such change is warranted by a change in the medical literature and medical community's views.