treatments are medically necessary when their motivations appear to be purely financial. CIGNA, by all accounts, did not act abberantly or in contra- diction with its own procedures. It abided by the contractual obligations of Bill’s policy language, even if it did appear to pursue its claims management aggressively. Everything Bill Mantlo went through, from his acute care through his various rehabilitations, reflect the inner workings of a healthcare deliv- ery system that functioned according to its design. This is not a case of the system breaking down, Mike believes. It is a case of a system designed to deliver results not all feel are just. “The only thing I can say to people in the industry is that I hope to God they never have to be in the same kind of situa- tion,” Mike says. “All it would take is for the president of CIGNA or any other health insurer to be in this kind of situation to real- ize that what they are doing is not such a great thing.” Wendell Potter feels very much as Mike Mantlo does. For 20 years, he handled public relations and corporate commu- nications for health insurance companies, the last 15 of which were with CIGNA. He left CIGNA in 2008 and now speaks out against what he saw as a troubling disconnect between the health insurance industry’s desire to make a profit and people’s desire to recover fully from injury and illness. He is now a senior analyst at the Center for Public Integrity, a nonprofit that pro- duces investigative journalism on issues of public concern. He is also a senior fellow on healthcare for the Center for Media nd Democacy, a public interest organization that argues for the need to overhaul the American healthcare system. And he is one of the few independent consumer liaison representa- tives for the National Association of Insurance Commissioners, attending their meetings in order to advocate on behalf of insur- ance consumers. In June 2009, Potter testified before the Senate Commerce, Science and Technology Committee in what would become a frequently cited argument for the need to reform healthcare. He said that in the case of insurers that are traded on the stock market—as CIGNA is—the need to meet Wall Street’s expecta- tions far outweigh the need to help policyholders get better. As such, insurers regularly find ways to scrub policyholders from their rolls who have conditions that will take a long time and lots of money to treat. Policyholders like Bill Mantlo, for instance, whose brain injuries are serious enough to merit on- going rehabilitation in order to restore his brain and motor func- tion, but persistent enough that no amount of rehab will ever bring him back to where he was before his accident. For health
insurers, a policyholder like Mantlo is a worst-case scenario. After receiving the details of Mike’s struggle with CIGNA, Potter says that sounded consistent with how CIGNA typically handled such cases when he worked for the company. But he adds that CIGNA is hardly unique in this regard. If anything, how CIGNA deals with policyholders like Bill Mantlo is par for the course across the health insurance industry, Potter maintains. “Medical directors in cases like this are under the gun to make sure they are keeping medical expenses to a minimum,” says Potter. “There is often a review of cases on a periodic basis by medical directors and they’ll look at the benefit plan and if there is any reason to reduce or deny coverage, they’ll do it.” Potter notes that CIGNA also does this to small businesses deemed to have excessive medical costs, in a practice known as “purging.” The strategy is simple: identify those small busi- ness policyholders whose costs are too high and systematically increase their premiums until the businesses are forced to drop their coverage. By then, the business has a hard time finding coverage with another insurer because of its claims history. “This is a big reason why we have a dwindling number of small businesses that can offer coverage.” Potter has no specific information on Mantlo’s policy, and he refers the matter to Gloria Barone, an ex-journalist who currently handles CIGNA’s corporate communications. “Gloria is a good person, ” Potter says, adding that she probably will be unable to provide any helpful information on Mantlo’s case. Potter’s as- sessment proves correct on both counts. As Barone listens to an account of Mantlo’s career, his acci- dent and his descent into healthcare purgatory, her response is a human, sympathetic one. Every detail of Mantlo’s case seems to trouble her on the same personal level that it troubles almost anyone who learns of Mantlo’s condition. Her professional reaction, however, is one of guarded pes- simism. She says that for legal reasons, she is prohibited from disclosing the details of Mantlo’s coverage as provided by the Legal Aid Society. When told that Mike Mantlo is willing to sign a HIPAA waiver on his brother’s medical records, she later reveals that CIGNA no longer has the paperwork on Bill’s file. Moreover, nobody at CIGNA is willing to discuss Bill Mantlo on record. (In fact, CIGNA would not comment on any aspect of Bill’s medi- cal history as described in this article.) Most of the people who handled his case, she says, are no longer with the company. She will not say who those people are. Same for the Legal Aid Society. Nobody at the Society who worked there at the same time Mantlo did knew him very well,
