State reverses one-third of health insurer decisions

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When an insurer denies a patient’s claim, Connecticut residents can fight the decision.

Perhaps surprisingly, these challenges to bureaucracy aren’t futile. CT Insider analysis of state records finds, for example, that 1 in 3 challenges to health insurers over the past decade were decided in favor of the patient.

Data from the Connecticut Insurance Department identifies insurers and types of claims that are the target of complaints. Some industries saw more overturned decisions than others; decisions by health insurers and pharmacy benefit managers had the highest rate of reversal.

In 2025, Connecticut policyholders filed over 5,000 complaints with state regulators. Those regulators are empowered to intervene or even require state-licensed insurance companies to reverse decisions. The complaints we reviewed cover disputes across every industry, from auto insurance to denials of coverage for medical care.

Many of these cases never receive a decision, instead being dismissed on technicalities or withdrawn. In those cases, a verdict on who was right or wrong never arrives.

More interesting are the decisions state investigators make in cases that are pursued to the finish line. Health insurance companies dominate that ranking, occupying positions one through eight in the ranking of companies with the highest rates of being overturned by the state. The complaints date from 2015 through present, although most were filed after 2022.

Among firms with at least 20 complaints, the most-frequently overturned decisions stemmed from complaints about CaremarkPCS, the pharmacy benefit manager owned by CVS Health. The state rejected the company’s position in nearly half of complaints where they reached a decision, records show.

Phillip Blando, a spokesperson for CVS Caremark, told CT Insider he could not comment on our findings.

The company with the second-most decisions overturned was Quantum Health. According to Quantum, their company doesn’t actually author the decisions at the heart of the complaints. Instead, Quantum sits between the patient and the insurer, meaning that the complaints target unidentified insurance companies. The company declined to comment on the state’s complaint data.

Still, Quantum was named in nearly 200 complaints. In 46% of complaints where investigators ruled, that finding was overturned. Most of Quantum’s complaints were categorized as denials in which the insurer told patients that a treatment wasn’t medically necessary.

In third position was Cigna Health and Life Insurance Company. The company’s initial decisions were overturned 44% of the time, mostly centered on delays in and denials of coverage.

A spokesperson for Cigna said they couldn’t independently verify CT Insider’s analysis. In an emailed statement attributed to Justine Sessions, the spokesperson said Cigna is “committed to paying claims quickly and correctly, and to resolving issues when they arise.”

Cigna policyholders are suing Cigna for allegedly using an automated decision-making system to rapidly issue denials for medically necessary care. Cigna has called the lawsuit “baseless” and attacked the credibility of reporting about its software, which was first documented by the investigative news site ProPublica in 2023.

As a percentage, Cigna also settled more of its complaints than any other company in Connecticut, followed by Oxford Health Plans, a subsidiary of UnitedHealth. UnitedHealth is the target of federal lawsuits from patients and hospitals alleging that the company wrongfully denied patients’ claims.

In over 40% of non-dismissed complaints filed against Oxford Health, the company was either made to pay or a compromise was reached where Oxford met a complainant halfway.

Across the state’s five big health insurers, the state ruled in favor of patients around 34% of the time. If you think an insurer’s decision was wrong, then, the data suggest that filing a complaint is at least worth a shot.

Distributed by Newsbank, inc.

The post State reverses one-third of health insurer decisions appeared first on Insurance News | InsuranceNewsNet.

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