LANCASTER — A former Lancaster Elementary School nurse has sued her insurance provider, claiming it repeatedly refused her requests for a lumbar-spine MRI that she says would have quickly found the tumor that has left her a paraplegic.
In a lawsuit filed in Coos County Superior Court, Carolyn Daigle, 50, and her husband, Roger Daigle II, of Jefferson, are seeking a jury trial.
The suit names the New Hampshire School Health Care Coalition, also known as SchoolCare, of Manchester; the program’s administrator, CIGNA Health and Life Insurance Company, of Bloomfield, Conn.; eviCORE healthcare, MSI, of Franklin, Tenn., which is identified as a CIGNA subsidiary; and two eviCORE healthcare employees, Tiffani Forbes, M.D.; and Gregg Allen, M.D.
According to the Daigles’ lawsuit, which was filed by attorney Nick Abramson, Carolyn Daigle was an active wife and mother who in the latter part of 2017 suffered a fall while helping an elderly relative get out of the shower.
Abramson said Daigle’s “bright future has been sacrificed to avoid paying for a $2,000 MRI.” Daigle “should be able to live the life she worked so hard to obtain,” he said in a statement, but, “instead, she will spend the rest of her life in a wheelchair.”
On Oct. 25, 2017, Daigle went to see John Ford, M.D., her primary-care physician, for a complete physical exam. She told him she felt hyperextension and pain in her back, according to the suit. Despite a treatment regimen that included an over-the-counter pain reliever and therapeutic yoga, Daigle’s pain got worse, and at times forced her to crawl on her hands and knees, the suit says.
When Daigle returned to Ford on Jan. 10, 2018, he asked CIGNA to approve an MRI for her, but the company on Jan. 15 said the procedure was “not medically necessary,” the lawsuit reads.
According to the suit, Ford then called eviCORE healthcare directly and had a “peer-to-peer” discussion with a physician, who denied the MRI, again, for the same reason.
On March 15, 2018, Ford once more sought permission from CIGNA for the MRI and once more CIGNA denied the request, the lawsuit claims. Six days later, Ford had a second “peer-to-peer” phone conversation with an eviCORE healthcare physician, who ordered the MRI, according to the suit.
Conducted on March 28, 2018, the MRI, said the lawsuit, “immediately revealed” that a mass on Daigle’s spine “now encompassed three vertebrae in the center of her back in close proximity to her spinal cord.”
Even though it was promptly removed, the mass, determined to be a non-cancerous schwannoma, had already caused “irreversible damage” that left Daigle “permanently paralyzed below her ribcage,” the suit says.
The lawsuit questions both the rationale used by CIGNA and eviCORE healthcare to deny Carolyn Daigle’s and Ford’s requests for an MRI and Forbes’ and Allen’s qualifications.
Forbes, the lawsuit said, is an internist at eviCORE healthcare “who appears to have little, if any, clinical experience with spinal imaging or spinal pathology.” Forbes, the lawsuit continued, denied Daigle’s MRI request without ever speaking with her, seeing her or communicating with Ford.
The lawsuit, which alleges that CIGNA and eviCORE healthcare’s actions were motivated by greed, goes on to say that to provide “further cover” for the MRI denial, Forbes’ determination was “rubber-stamped” by Allen, who is ostensibly her supervisor.
The justification for the denial was based on “secret guidelines it (CIGNA) created but hadn’t disclosed to Carolyn or her doctor,” the lawsuit said, specifically noting that Daigle had allegedly failed to engage in a six-week trial of doctor-prescribed treatment and/or observation, with no demonstrated improvement and including a follow-up visit with her primary-care provider.
Not only does that provision “not appear in any of the health benefit plan materials previously provided to Carolyn Daigle,” the lawsuit says, but “the truth is that Carolyn Daigle, in fact, met this secret requirement” by presenting her symptoms to Ford in October 2017 and, from that point forward, following his treatment plan.
CIGNA had that information, as well as reports from Ford about Daigle’s condition, when it rejected the requests for the MRI, the lawsuit says.
On Wednesday, Mark Slitt, CIGNA’s public relations senior adviser, said in an email that the company is “not able to comment on pending litigation.”
The lawsuit seeks compensation for Carolyn Daigle’s economic losses, permanent impairment and disfigurement, past and future loss of enjoyment of life, future physical pain and suffering, and emotional distress.