David Whelan

Forbes, NY
Jan 8 2008

Right before Christmas, Nataline Sarkisyan, a 17-year-old in Los
Angeles, died after a hard-fought bout with leukemia that ended with
a failed attempt at a liver transplant. The tragedy took on symbolic
importance after Sarkisyan's parents and brother blamed her health
insurer, Cigna, for her death.

The death triggered a lawsuit promised by a celebrity lawyer and
a political protest by the California nurses union, and became a
campaign issue for John Edwards, tapping into Americans' anger about
a health system they find complex, expensive and callous. But as the
furor grows, a big question remains unanswered: Does Cigna (nyse:
CI - news - people ) deserve all the blame?

It's an important question to resolve. The Sarkisyan case raises
broad issues about the transplant system, the rights of patients and
the actions of insurers and doctors in life-and-death cases. Does
a person need insurance to pay for a transplant to get one? Why did
doctors wait for clearance from an insurer to do the operation? And
most important: Was a liver even available?

The California teenager started suffering from leukemia, a deadly
cancer of the blood, when she was 14. At first, the cancer went into
remission. Then this year, the leukemia relapsed. Before Thanksgiving,
Sarkisyan's brother Bedros donated bone marrow for a transplant that
was successful at putting her disease back into remission.

But then it took a turn for the worse. Sarkisyan's liver failed
from a blood-clotting complication. She was put on life support. Her
doctors--an oncologist at Children's Hospital Los Angeles and four
members of the organ-transplant department at the University of
California-Los Angeles--tried to get her a transplant.

On Dec. 10, Sarkisyan and her doctors made the first request for Cigna
to pay for the liver transplant. Her family said that a liver had
become available that day. A day later, a Cigna-employed physician,
Stephen Crawford, wrote back and said that the health-insurance policy
would not pay for it. In the letter, Crawford says that Sarkisyan
was too sick for the surgery to work.

Sarkisyan's four UCLA doctors immediately wrote back to Cigna,
appealing the decision. They argued Sarkisyan would have a 65% chance
of surviving for six months after the liver transplant, based on
studies of similar patients. The doctors reckoned Sarkisyan had an 85%
chance of avoiding a recurrence of cancer because of the successful
bone marrow transplant.

Cigna hired an oncologist and transplant surgeon to review the appeal
but never reversed its clinical decision.

Soon the California Nurses Association, a powerful union lobby,
got involved. It joined Sarkisyan family and friends in protesting
Cigna's decision. On the Dec. 19, the nurses announced a march on
Cigna's Glendale, Calif., offices.

The family also hired a lawyer, Mark Geragos. Geragos is known
for representing singer Michael Jackson and convicted murderer
Scott Peterson. The Sarkisyan family knew Geragos as a fellow
Armenian-American who had helped raise money for an Armenian bone
marrow bank.

On Thursday, Dec. 20, 150 nurses picketed Cigna. Many more called the
company. Later that day, Cigna contacted Geragos and UCLA to say it
was making a one-time exception to the process and would cover the
treatment. Though the company still believed it was experimental,
it would pay out of its own pocket (not that of Nataline Sarkisyan's
mother's employer) for the procedure.

But Cigna's reversal came too late. That same day, Nataline Sarkisyan
was taken off life support and died.

A day after their daughter died, the Sarkisyans held a press conference
with Mark Geragos to announce a lawsuit against Cigna.

Geragos said that he believed that criminal prosecutors should
press murder charges against the company for killing Nataline. "The
implied-malice murder theory has been expanded greatly in California,"
he says. (So far, no such charges have been pursued.)

That weekend, vigils were held by the nurses and family. At some
point, John Edwards began referring to Sarkisyan's death in his
speeches. Internet bloggers also blamed Cigna for the young woman's
death. Cigna's move to pay for the transplant at the 11th hour was
interpreted to be a cynical too-little, too-late maneuver.

Yet nobody involved with Sarkisyan's medical care has ever spoken out
about the case. The doctors are forbidden from discussing it unless
the family signs a privacy waiver. Lawyer Geragos says the family will
only sign the privacy waiver once a lawsuit is filed in a few weeks.

The mysterious part of the narrative is whether a liver was truly
ready to be transplanted. If there was a liver, why was it held up?

It's not enough for the insurer to deny coverage. The doctors and the
hospital--especially a nonprofit institution like UCLA--must decline
to work for free.

"There have been occasions where UCLA has performed a transplant
without compensation," says Roxanne Moster, a spokeswoman for the
hospital. She says, cryptically: "The physicians at UCLA Medical
Center base decisions on the medical condition of the patient." She
also mentions that money is an issue with transplant patients because
even if UCLA pays for the procedure, there is a lifetime of expensive

A spokesman for Children's Hospital Los Angeles, where Sarkisyan's
oncologist works, declined to comment.

That leaves a few possible interpretations: 1. There was never a
liver. 2. There was one but the doctors were reluctant to transplant
it without Cigna's payment. 3. The doctors would have eventually
done the transplant without payment, but in the meantime, the patient
died. 4. The family did not want the transplant to go forward unless
Cigna paid for it.

Cigna's medical director Jeffrey Kang, a physician who used to be
a high-ranking official with the Centers for Medicare & Medicaid
Services, says there is no way that Cigna can stop doctors from
performing a liver transplant. A national organization called the
United Network for Organ Sharing manages the waiting lists. One of
UNOS' principles is that patients should get transplants regardless
of their financial means. "Some people have said we denied a liver,"
Kang says. "But the reality is we only denied paying for it."

Geragos is somewhat cagey about the details of when a liver became
available. "The family was on the ground there. We will put forth what
they were told," he says. "I don't want to tip our hand to Cigna as
to what we have, smoking-gun-wise." Did Cigna stop the transplant?

Geragos says he's sure of it.

What about the theory that UCLA should have, or would have, gone
forward with the transplant if a liver had in fact been available?

"Let them say it," Geragos says. "We will cram it down their corporate