Health insurance companies such as Aetna win when they deny valid claims and the insured doesn’t fight back. Aetna, for instance, collects more than 30 billion dollars in premium revenues in any one financial year. And while this may appear like an obvious financial ability to pay valid claims, Aetna continues to delay and deny coverage. Aetna knows that giving the insured an eternal runaround or out rightly denying claims can often increase their profits. Unfortunately, Aetna and other huge health insurance providers act in bad faith more often than you might think. They bank on you not putting much of a fight when they delay benefits or ask you to settle a claim for less than it is really worth. If you submitted a claim for health or disability insurance coverage to Aetna and were denied or delayed benefits after an appeal or at the initial stage, Stop Insurance Denial Law Firm is here to help you. We work with policyholders who thought they were protected only for their insurer to deny their claims. Contact us online today or at 310-878-1771 for immediate help with your Aetna claim.
Overview of Aetna Insurance Denial and Delay
Health insurance and disability insurance policies are contracts between the insured and the insurance carrier. For this reason, insurance providers such as Aetna are required by law to act in good faith and fair dealing. This means that neither the policyholder nor Aetna would do anything to injure the other party’s rights to receive benefits of the contract. For the policyholder, this means they get the coverage guaranteed under their insurance policy. For the insurance provider, it means they receive premiums from the insured. Nonetheless, all too often Aetna delays and denies claims by citing seemingly mundane reasons, leaving policyholders with huge medical debts that they have to pay for out-of-pocket. Even if they accept a claim, health insurers such as Aetna are notorious for offering lowball settlements on health insurance claims. Aetna may refuse to pay for a treatment or procedure and instead suggest a lower cost course of treatment. Also, they often offer to cover only a partial reimbursement of a procedure or treatment.
Health care costs have dramatically peaked over the years. The national average cost for a day’s stay in a hospital is somewhat above $2,000, according to a report by the Henry J. Kaiser Family Foundation. In California, for instance, the cost for an individual to stay a single day in the hospital was closer to $3,725 at a non-profit hospital and $3,000 in a government hospital. These numbers show just how crucial it is for a policyholder to receive the coverage they need to offset such bills.
If your health or disability benefits have been denied, Aetna may have claimed the following:
- The procedure is merely cosmetic and not medically necessary
- The treating physician is out of network or out of plan
- The claim filed was for a medical condition that isn’t authorized or covered
- Medical treatment or procedure is investigational or experimental
- The policyholder misinterpreted something in their original application
- The policyholder failed to disclose a pre-existing condition
- There were issues with documentation or paperwork
- The medical examinations were inadequate or insufficient
- You failed to disclose a pre-existing health condition
Even though you’ve been paying for your premiums every time they are due, you may end up being a victim of Aetna’s insurance denial practices, and this could mean losing the financial security you thought you could count on. Unfair denials may lead to loss or foreclosure of your property, loss of income, loss of your savings, or the inability to access medical care. Luckily, if Aetna or any other insurance company has denied your health or disability claim, it isn’t the end of the road for your claims process. It’s important that you know your rights and the legal options you have if you’re a victim of Aetna’s routine denial practices.
If Aetna denied your health insurance or disability claim, it’s your right to appeal their decision and you can successfully do this with the help of an Aetna health insurance denial attorney. A lawyer can help you through the complexities of insurance law and appeals and work to ensure that you recover the coverage you need for a procedure or help secure compensation you need for your losses.
Aetna’s Disability Insurance
Aetna provides both long-term and short-term disability insurance to allow individuals to fill their income gap in the event that they are injured and need to take some time off of work.
- Aetna Short-Term Disability
If you suddenly cannot work for a certain period of time, Aetna’s short-term disability coverage is meant to help cover a percentage of your income while you’re recuperating. Aetna provides coverage for certain injuries and illnesses that qualify as disability and are well defined in every plan’s summary. To start collecting your disability pay at Aetna, you must have missed a certain amount of days from work. You will be allowed to collect your disability for an assigned amount of time before you can be able to switch to long-term disability insurance if you’re eligible and have chosen to obtain this through your employer.
- Aetna Long-Term Disability
Just like with the short-term disability plan, Aetna’s long-term disability insurance also has limitations. The main difference is how long you are able to receive disability pay through long-term disability insurance. The pay for Aetna’s short-term disability plan is based on time, whereas the pay Aetna’s long-term disability plan is based on policyholder’s age at the time of becoming disabled. However, there are a few exceptions to this rule. If your disability resulted from a psychiatric condition or mental health, or from drug or alcohol abuse, your payments will stop coming in after 24 months. If you’ve been sent to a treatment facility or have to be hospitalized because of substance abuse or mental reasons, you may continue receiving your benefits for a while longer.
Understanding Your Rights as a Policyholder
Purchasing and paying for health insurance gives an individual a sense of security and peace of mind since it seemingly assures policyholders that they would be in a position to see the doctor and afford proper medical care if they ever needed it. However, if Aetna denies an insurance claim, it’s imperative for a policyholder to understand his or her rights as far as getting the coverage they need and deserve is concerned. In general, as a policyholder, you have the right to:
- Information (in writing) about why your healthcare coverage or claim was denied
- Scrutinize and retort to all information used in Aetna’s decision
- To file an internal appeal with Aetna
- Engage in an independent, external review of the appeal
How Long is too Long? Aetna Claims Delay
A common misconception about the insurance industry is that insurers generate their revenues from the premiums that policyholders pay monthly or yearly. But the truth of the matter is that insurance providers invest your money and that of other policyholders in ways that enable them to make even more money. Eventually, the money that insurance providers pay out as compensation is just but a fraction of the premiums paid by the insured.
What this means is that each day the amount of money you’re entitled to sits in Aetna’s bank account is another day they collect interest on the money. While this may not appear to be too much to generate that much of a profit, think of the interest of hundreds or thousands of claims that are unpaid. These claims add up whenever the money is in Aetna’s reserve. Aetna generates profits from delaying, denying, and underpaying claims. If insurers pay all valid claims in a timely manner, they would have less money to invest into other ventures, and, hence, lose or generate less money. By delaying valid claims by employing numerous illogical and capricious strategies, insurers can seek to hold onto your coverage. An experienced Aetna insurance delay attorney from Stop Insurance Denial Law Firm can help ensure that Aetna or any other health insurance company doesn’t delay your claims unreasonably.
Appealing a Claim Denial from Aetna
An internal appeal gives you a chance to request an insurance provider to have a fresh look at your denied claim. If you’ve received a claim denial letter, you may initiate an appeal by submitting your request in writing or by printing and mailing the appeals form. Before submitting your appeal, it’s important to consult with a nationally recognized Aetna insurance attorney because you may only have one chance to submit an internal appeal. Failure to provide the necessary or adequate documentation could mean voiding your benefits.
When submitting an appeal regarding your denial by Aetna, you’ll have 180 days or 6 months from the time you receive the denial notice. The time may be shorter or longer depending on plan policies. A seasoned Aetna insurance denial attorney can help you understand these deadlines and file your appeal within the stipulated time.
Generally, Aetna will give you specific information that must be included in your written application for appeal, including:
- Your name
- The group name (employer or company sponsoring the plan)
- Any and all pharmacy and testing records, medical documents, and other information you’d like the carrier to consider showing the medical care you’ve received or procedures you’ve undergone or those that you need to receive
The Next Step if You’ve Exhausted Your Appeals and Aetna Still Denies Your Claim
While an internal appeal is the first line of action to get health insurance benefits after a denial, chances are that Aetna will still uphold their decision. If you’ve exhausted the appeals allowed under your plan, you have the option of requesting an external review with an independent physician. Aetna allows members to request an external review for coverage denial based on the experimental or investigational nature and lack of medical necessity of the supply or service at issue. A policyholder may participate in Aetna’s external review if they have exhausted the applicable plan appeal process and the coverage is one that the policyholder would be financially responsible for more than $500 of the medical costs. An external review is not a precondition for seeking the court’s intervention if Aetna has wrongfully denied your claim. It’s not a move you should automatically make without the help of an attorney because in some cases it may more beneficial to file a lawsuit and skip the external review process.
You can also file your complaint for benefits with ERISA. The Employee Retirement Income Security Act of 1974 (ERISA) is a federal statute that applies to employees whose Aetna insurance plans are provided by labor unions and private employers. Disability insurance plans just like other parts of an employee’s benefits package are subject to ERISA. Under ERISA provisions, Aetna can face liability for not disclosing enough information about your disability plan. It’s Aetna’s duty to inform you about your policy provisions in a manner that can be deemed adequate by a court of law.
Typically, a denial for a group disability coverage by Aetna will fall under ERISA. The main reason for enacting ERISA was to protect workers. But insurance companies use it to hurt disabled employees by denying legitimate disability claims. However, it’s important to understand that you have fewer rights under ERISA because the law curtails what you can do and how you can do it.
Suing for Denied “Medically Necessary” Treatment
When a pre-approval request or a claim has been submitted, the insurance company –not the medical provider- ultimately decides whether a service, treatment, procedure, or device is “medically necessary” and will be covered. Under our insurance system in the U.S., the threshold of medically necessary treatment is often the threshold for when an insurer must cover a policyholder’s claims. Other alternative procedures may be good for you and recommended by your doctor, but your plan might not cover them. Your insurance company can deny your benefits if they see the treatment of procedure as options rather than life-saving.
The main issue with the recent Aetna case is that the insurer made decision with no medical basis. In one case, for instance, a former medical director from Aetna confessed under oath that he never researched the condition a policyholder patient was seeking treatment for, did not know what drugs were effective in treating rare conditions, and actually never went through submitted medical records. He was in charge of approving or denying treatment and procedures as medically necessary. When asked if treatment for a rare condition would be approved or not, the director outrightly denied the procedure’s necessity and the claim.
In such a case, a patient can sue for wrongful denial of coverage, breach of contract and bad faith in claiming that the treatment wasn’t medically necessary. An insurance company may be considered to have acted in bad faith if the claim was denied without any real research, medical opinion, or investigation.
Damages for a Lawsuit Against Aetna
If you’re not able to get a pre-approval for medical treatment or procedure, you may be forced to pay out-of-pocket for the treatment and may even be unable to receive treatment entirely. This may result in the deterioration of your condition. This could consequently lead to increased medical costs down the line, extreme pain and suffering, and inability to work. In extreme cases, denial of health insurance claims may lead to the demise of the claimant.
If your claim has been wrongfully denied, you may be entitled to compensation for the pain and suffering and all of these financial losses. Conversely, you may be entitled to receive compensation if the wrongful denial led to the death of a loved one. This compensation may cover their loss, burial costs, their suffering, and other similar expenses.
On the other hand, it can be catastrophic to stop treatment if your claim is denied. And if your insurance provider declines to continue coverage for your ongoing care or you opt to switch to another insurer during your treatment, the impact could be terrible. The pain and suffering from abrupt withdrawal of treatment may take a terrible toll on your health, leaving you vulnerable to complications or further incapacitated. You could be entitled to substantial compensation if Aetna’s decision to deny your claim or cancel your benefits was unreasonable. Also, if Aetna’s review of your claim was handled with negligence or in bad faith, you may be entitled to receive punitive damages for the denied benefits.
Finding Aetna Health Insurance Denial Help Near Me
Aetna and other large health insurance providers are businesses that want to make profits. While this is okay, it should not be at the expense of the health and well being of policyholders. If Aetna is taking too long to provide coverage or you’ve received a denial letter regarding your health or disability insurance claim, you should seek help from an attorney at Stop Insurance Denial Law Firm. We take on large health insurance companies such as Aetna that wrongfully deny much deserved and needed insurance benefits- and force them to fulfill their contractual obligations.
Our nationwide health insurance denial attorneys diligently evaluate cases against all major insurance company and handle a wide spectrum of claim denials, from a few thousands to claims worth millions. We’re here to help fight for your benefits when Aetna has let you down. We leave no stones unturned and are always prepared to devote our legal expertise and resources to the case.
Fill out our online contact form or call our office at 310-878-1771 for a complimentary consultation with one of our experienced attorneys.