Aetna, Inc.

If you ever had a choice of medical insurance, and aetna is one of them - RUN the other way, as if you life depended on it.
My company switched it's insurance from [redacted] to Aetna in July 2014. They promised to roll over the previous deductible from [redacted] into Aetna. My rollover didn't take place until Oct, after a consistent weekly, drawn-out calls with reps and finally supervisor.
During the period of July-Oct, medications were prescribed, which I paid 100% for, but should have only been billed at 50%. When the rollover FINALLY applied in October, I was sent to the "pharmacy" section to work with them on getting the overpayment of medication sent back to me. Again, after daily drawn-out "conversations" with the pharmacy department, a "resolution specialist" (not quite a revolutionist, neither a specialist) told me that it was finally resolved, and a check would be sent out to me on Oct. 22, 2014.
The last week of October rolled by. No check in sight. I called. They told me I have to be patient and wait. It's ONLY been a week.
Fine. First week of November came. No check in sight. I called. They told me I have to be patient and wait. The excuse now: It's being processed.
How did it go from it's sent, to wait, to now being processed? So the check never existed, and never left the building.
It is now the second week of November. Twenty-two days have passed. I called to enquire the whereabouts of this VERY elusive check. After being passed from a rep, to a resolution specialist, and then a supervisor, they finally tell me, that a check was NEVER issued. NEVER processed. The amount due back to me was never reinstated BACK to me. Meanwhile, that said amount has been removed from my total out-of-pocket amount.
THIS IS WHAT YOU CALL DAYLIGHT ROBBERY!

Review: [redacted] advised me that I needed more clinical information to support my short term disability claim appeal case. I contacted Aetna using the website email contact us link advising that the final test that was needed to support my claim will be performed on March 12th and the test results would not be available until March 22th. I asked could my claim be either put on hold or extended until March 24th. I received an email back from Aetna saying that they understand my request and have forwarded the dates of my procedure and results to my claim manager [redacted]. The morning of March 22nd, I faxed over the test results to support my claim. Ms [redacted] told me that she made her decision on the 19th of March and if I knew that the test results were not going to available then I should have contacted her to put it on hold. I advised her that I sent an email through the Aetna website and also left voicemails regarding the test results. Ms [redacted] said she did not have any record of any email or phone call. I called Aetna back and spoke to a representative and asked does it show the email that I sent on Feb 26th and the representative read back exactly my request and confirmed that I did indeed follow the correct procedures. Ms [redacted] ignored the information that was forwarded to her on my behalf and purposely denied my claim before my test result were in. I asked Ms [redacted] what is the next process and she advised me that the only thing that I could do would be to file a civil suit.

Product_Or_Service: Short Term Disability Claim

Order_Number: XXXXXXX

Account_Number: XXXXXXXXX

Desired Settlement: I would like my test results to be evaluated, my past due health benefits paid and also my short term disability paid out immediately.

Business

Response:

Business Response /* (1000, 5, 2013/04/05) */

Thank you for your inquiry received on March 27, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to the Disability department for assistance with the member's concerns. Based upon review of the information submitted, they have overturned their original decision to deny the member's benefits. As a result, the claim has been returned to the Claims Operation Team and will be reviewed for benefit payment, effective November 13, 2012 through January 8, 2013. Any benefits owed will be processed separately. Their records reflect that the member returned to work on January 9, 2013.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address these concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted].com.

Review: On August XX XXXX,I went to the only clinic that was open after I got off work at 6pm & waited 3 hours to see Dr. [redacted] for the consistent headaches that I had been having for about a month.He and the scribe spoke with me about my condition of anxiety which I have suffered from for years & he eventually advised that I stay away from work due to the environment & the nature of the job for 4 weeks.After payment,I was issued a doctors note for work & assured that I just needed to call Aetna,initiate a claim, & the rest would be taken care of.I also emailed management to inform of the situation & that I would be out of work until September XX XXXX on short term disability.I checked on the progress of the claim periodically & was informed that information had not yet been received.I called the doctors office who informed me that Aetna had not yet sent a request for medical records.This began an endless and exhausting back & forth runaround for the next four weeks.Eventually I was advised by Aetna to issue the doctors office a request for medical records in writing so that they cannot ignore it.Once this was done,I was advised by the medical staff that records take a day to prepare for issuing & to come back for pick up.By the time I picked up the records which consisted of 2 pages(a page for each visit I had with the doctor) the very next day & had faxed them to Aetna myself,it was 1 day too late & my claim had been denied for payment,but approved for acceptable time off which ensured security of my position.The next day,September XX XXXX, I returned to work & filed an appeal.I called on 2 occasions to check the status of the appeal.I was informed that everything was going smoothly & that a psychologist was reviewing the claim.I was also informed that I would be updated if anything was needed.On January XX XXXX,I received a letter stating that my appeal was denied due to the fact that a written request request for additional information was sent to the doctor & was ignored on December 3 & X XXXX.

Product_Or_Service: insurance

Desired Settlement: Aetna denied my claim for short term disability that should have been granted on the fact that a reasonable effort was not made on their part as promised to get in contact with me once the doctor ignored the request for information to properly process my claim and appeal.Fair resolution would be payment of the 4 weeks that I was pulled out of work in the amount of $1723.68 before taxes.Aetna's policy is that a short term leave is paid at 0% for the 1st week and at 100% for the 3 weeks following.

Business

Response:

Business Response /* (1000, 5, 2013/04/10) */

Thank you for your inquiry received on April 3, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to the Disability department for assistance with the member's concerns. They advised this claim went through the appeal process and was upheld due to a lack of medical information to demonstrate a functional impairment that would prevent him from performing his own occupation. The file was reviewed by a peer physician who attempted to speak to the treating provider, Dr. [redacted] on December 3, 2012 and December 5, 2012, but was unsuccessful. The peer reviewer's findings were sent to Dr. [redacted] on December 26, 2012 for his review and comment, but no response was received.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address these concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]com

Consumer Response /* (3000, 7, 2013/04/11) */

(The consumer indicated he/she DID NOT ACCEPT the response from the business.)

I'm baffled at the inconsideration of Aetna. I do not accept the response because it was not reviewed by an executive team; The response shown above was copied and pasted from my denial letter, thus it does not address the fact that an effort was ever put forth from Aetna to contact me when the doctor did not respond. The doctor is not going to respond to Aetna. Aetna were informed of that and was asked to contact me for information so that I may act as a liaison between the doctor and Aetna. It was demonstrated that the doctor will not respond to requests from Aetna in the original claim (I am currently going through the appropriate channels to properly complain against this facility as well). This is in my notes taken by the many Aetna representatives that I have spoken with. I was told that this is a reasonable request; however, this was not honored.

Business Response /* (4000, 9, 2013/04/16) */

Thank you for your inquiry received on April 12, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to the Disability department for assistance with the member's concerns. They advised the claim was called in on August 22, 2012 and the Attending Physician Statements were received on September 5, 2012. This information was reviewed and determined to be insufficient to support the member's disability. Ms. [redacted] was informed on September 10, 2012 by a customer service representative that the office notes would be required. Her doctor was contacted on September 11, 2012 by the nurse case manager for additional information. This information was not received and the decision was to deny benefits on September 17, 2012.

On appeal the claimant did have the opportunity to send in this information, which we received on October 9, 2012. We reviewed the records which did not support her disability. The peer physician tried to contact her doctors for a discussion but was unsuccessful. The peer physician provided his conclusions in a report, which were faxed to the treating provider for his rebuttal. There was no response received and the appeal decision was to uphold the denial.

It does appear that we have all the documentation and her disability is still denied based on medical evidence, not lack of response from her attending physician.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address these concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]com.

Consumer Response /* (4200, 11, 2013/04/17) */

(The consumer indicated he/she DID NOT accept the response from the business.)

From the response, I did get all information in for review; however, the explanation states: "It does appear that we have all the documentation and her disability is still denied based on medical evidence, not lack of response from her attending physician."

If I did what I was suppose to do, where did my review go wrong? Did this physician have a right to pull me out of work?

I have never been through this process before and simply chose a random physicians office and did as told; however I am being punished because the doctors notes aren't detailed enough? But then you state that I was not denied due to lack of response from the physician. May I please have clarification as to what went wrong, please?

Business Response /* (4000, 13, 2013/04/23) */

Thank you for your inquiry received on April 19, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We again reached out to the Disability department for assistance with the member's concerns. The member's claim was denied as there were not enough medical findings to support the disability. During their appeal review process, the Disability department attempted to have their doctor reviewer call the treating provider for a phone peer to peer consultation. They weren't able to connect. The appeal review process was completed based on the documentation they had on file, which appeared to be all of the medical documentation available for the review. The peer to peer process was to give the treating provider a chance to speak with the reviewer and/or offer any more documentation to help with any disagreement the provider may have had with the opinions of the doctor reviewer. Although the member may have a doctor who provides statements indicating he/she supports the members absence from work, the [redacted] Short Term Disability (STD) plan needs a showing that the health problem, treatment and signs are of the severity to preclude work in the claimant's specific occupation. After their full review, the medical information on file did not support the claimed disability.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the chance to address these concerns. If you have any more questions about this particular matter, please contact the Executive Resolution Team at [redacted]com.

Review: Aetna has stated that they would send a claim from 8/21/14 for Dr. [redacted] through to be reprocessed as this was my [redacted], however, this claim was not reprocessed and has not been paid. They have stated this more than once but, nothing has been done.Desired Settlement: I would like them to pay the doctor's bill.

Business

Response:

Hello,

Review: I filed a short term disability claim on 03/20/15, still to this day 6 weeks later I have not received my check, I have made several calls and am always told the same thing 7-10 business days, its day 40 and now they are telling me again another 7-10 business days. I have asked for a supervisor or case manager to call back, yesterday they said with in 24 hours that was at 10:00 today, [redacted] is my case manager and they say she is in meeting everytime I call. I need some help and a resolution.Desired Settlement: DesiredSettlementID: Other (requires explanation)

I would like to receive the check as I am suppose to. Im not asking fo rsomething im not intitled to, just for them to do the job they are suppose to do.

Business

Response:

Hello,

Review: I received a letter of an unclaimed paid up life insurance policy that belong to my father. My father died 43 years ago. I can only assume that the policy was obtained in the 1940's. They failed to give the amount of the policy after being told to give them time for inquiries on the claim. The policy is already well past the point of being overdo but to continue to get the run around is ridiculousDesired Settlement: Process the claim because if I had not received the letter from Aetna I wouldn't have known that the policy existed. And I would like to know the amount as well as copies of said policy for my records. Thanks

Business

Response:

Hello,

Review: After having difficulty with [redacted], I called Aetna to verify [redacted] consult coverage with my plan. I was told that [redacted] consults are covered at 100% in-network, up to 6 visits. Because there is no local in-network [redacted] consultant in my area, I was required to get a medical necessity letter from my personal doctor before seeing an out of network [redacted] consultant. I immediately had my doctor send in the necessity letter. Finally after over 2 weeks waiting for Aetna to approve for out of network visits, I received an approval letter stating I would be covered to see an out of network provider at the highest benefit allowed. My first problem I would like to point out is, why should any woman have to wait over two weeks for approval for a [redacted] problem that needed more prompt attention? After two weeks of waiting, my problem was difficult to treat, making it very discouraging. My [redacted] consultant charged $80 for the initial visit and $50 for the one subsequent visit, which she required payment in full at the time of service, which would require me to file my own claim for reimbursement. I did pay in full each time and filed the claims promptly via fax. Initially the claims were denied because she put down on the paperwork the patient being my son whom I was breastfeeding (she says typically that's how the insurance company wants it written). But being I got the letter from my doctor for ME to be approved for out of network benefits, they denied the claim, as my sons name was on the claim. I called them to fix this and even had the [redacted] consultant rewrite the claim with MY name, and I faxed it in. The claim was continued to be denied as it was out of network. I called numerous times, stating I was approved for the in network rate. The claim was reprocessed numerous times and continued to be processed incorrectly, to what I was told should have been 100% in network coverage. I finally received partial reimbursement.Desired Settlement: I am now getting a bill from Aetna stating they overpaid me for the claims. I'm lost track of how much they actually sent me, but it was not $130. Now they are saying that they reimburse at 100% at mutually agreed upon contracted rate, which they told me today is only $25 per visit. Initially I was told the visits are covered 100%. How is one to know that they have a contracted rate and it is significantly less than what some consultants charge? I was expecting to have been reimbursed $130.

Business

Response:

Thank you for your inquiry received on 04/07/2014 regarding complaint#[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: My dentist suggested I needed to wear a night guard since I have signs of teeth grinding. I first asked her office to run a cost estimate and it turned out to be $73.60. It was an acceptable price so I agreed to proceed with the service. After I received the night guard, the dentist office sent me a bill of about $583.40 because insurance did not cover most of the expense. I called the dentist office on 5/26 and the associate from the billing department explained to me that the $73.60 was the cost for covering a minor. That didn't make sense to me as I am the sole owner of the dental insurance and I am obviously an adult. She asked me to call the dentist office to learn the details. The associate from the dentist office who answered the call told me that when they submitted for an estimate, Aetna gave the quote of $73.60 without mentioning the age limit. The actual cost is 900% above the estimate. The inability of Aetna and the dentist office to correctly communicate coverage limits and pricing resulted in me pursuing a procedure that I may have declined if the pricing had been correctly communicated. Someone needs to honor the original estimate of $73.60 and I am asking Aetna to take responsibility to resolve this.

I've sent the exact same complaint to Aetna back in May, however the company never responds.Desired Settlement: Honor the original estimate that was being misquoted by Aetna, so that the patient was only responsible for $76.30

Business

Response:

Thank you for your inquiry received on 07/08/2015 regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: In January of 2014 I purchased a senior graduation trip for my son with the company [redacted]. Along with the trip I also purchased a cancellation insurance policy thru [redacted] underwritten thru [redacted] ( a.k.a. Aetna ). On April 28th I contacted [redacted] to inform them we would need to cancel the trip based on medical reasons. I were refunded 50% of our cost minus the cost of insurance and deposit fees by [redacted]. I was told I would need to contact Aetna to file a claim for the additional $2507.50 that was owed to me. On April 22nd 2014 we received a call from my son's school telling us to get there immed. there were some issues with my son. Upon arriving it was obvious my son was very upset and so we took him home. He revealed to us he had been assaulted by another boy and was trying to deal with this but was falling apart. We immed. contacted our doctor who put us in touch with a wonderful psychiatrist. My son was seen several days in a row, put on several medications and diagnosed with [redacted]. His doctor advised us it was going to take a while to get him over the sexual assault and advised we cancel his trip. His name is [redacted] I filled out all the forms and mailed them back and Aetna denied our claim based on it being a mental disorder, an exception to their policy. I informed them that was fine, I would file the claim based on the [redacted] my husband suffered on 3/28/ 2014 and who was still under medical care for his condition. We had not planned to tell [redacted] everything that was going on with his Dad, we didn't want him to worry, nor miss the chance of a lifetime and cancel his trip. We prayed his dad would be fine. Aetna says yes file the claim on your husband. They are suppose to mail me the claim form because you cannot download this form on any of their sites. They cannot e-mail it, it must be written up and submitted to their claim dept. for their words. Four times I call, four times no claim form. On Dec. 1 after dealing with this for almost 6 months I finally just sent in the paperwork to appeal the first claim with the information for a new claim on my husband. I included a copy of the EOB, a letter from my husbands doctor, he bills from [redacted] where he was hospitalized and underwent a cardiac cath. a letter from my employer stating my contract had ended and I was laid off, acceptance of unemployment and a detailed letter explaining I met all the criteria to have this claim paid as per their policy two things that are covered are: serious medical issue resulting in hospitalization of student or parent, or loss of income due to loss of employment of parent when employee is a no fault. Fast forward to January. I contacted Aetna to see were we stood in this appeal and was informed they had not received info. I explained when I mailed, and that our 6 month appeal period was ending and was told not to worry it the info was dated prior to the end of our grace period it would be accepted. They said it was the holidays and people were just getting caught up to call back in a few weeks. I called back in March. [redacted] says he will research it and call me back. Nothing. Finally I call back and am told it was never received. I explained the situation, said I would try to get copies of all the documents and resend but was told my claim was closed. I asked why I couldn't open a new claim I was still within my 1 year period to file a claim and am told it won't matter. I am requesting a new claim form and submitting anyways. I have tried to deal with this company and am getting nowhere. I feel they have done nothing except run the clock down and lose everything I send them. The member ID is [redacted]. I would like this claim settled.Desired Settlement: I would like the claim for 2,507.50 to be paid.

Business

Response:

Thank you for your inquiry received on 04/13/2015 regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: On October 25th, 2012, I saw Dr. [redacted] my urologist, for a visit regarding kidney stones. Several months later, it came to my attention that Dr. [redacted]s office, [redacted] did not receive payment from Aetna, my insurance provider, for the visit. After several calls to both parties, including a conference call between Aetna and [redacted] it was determined that because of a clerical error at Aetna, an incorrect doctor's office was paid...a doctor's office that I have never been to. We are now more than one year past the original appointment date. With several recent calls with Aetna and [redacted] and another call between the two, I am in a holding period. Aetna claims that [redacted] will be paid when they retrieve the original funds from the doctor they paid erroneously, while [redacted] is rightfully demanding that they receive payment from either Aetna or myself. Last week, I spoke with [redacted] at Aetna who told me that she would be following through with the issue. I have received no return call and upon calling for [redacted], I was able only to leave a message. This issue has taken far too long to resolve, especially considering that both [redacted] and myself have done all that we can to get it taken care of.Desired Settlement: For Aetna to pay [redacted] immediately.

Business

Response:

Thank you for your inquiry received on January 31, 2014. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to Aetna’s business operations team for assistance with the member’s concerns. Based on our review Ms. Cupani’s claim number [redacted] was pended by [redacted] incorrectly as the required records needed had been on file for review. Ms. Cupani’s claim has now been expedited for immediate review so that further processing can continue at this time. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the chance to address these concerns. If you have any more questions about this particular matter, please contact the Executive Resolution Team at [email protected].

Review: In planning to replace a bridge of more than 20 years with two implants and a new bridge my Dr. office called Aetna to inquire about coverage. They were informed that implants were covered at 60% and no predetermination was required. After the implants were done Aetna covered one of the implants at 30% stating they paid the less acceptable treatment for this procedure.Implants require a prefabricated abutment which the crown/bridge are later mounted on. Aetna paid this procedure at a rate of 60% which is customary. The final part of this overall procedure is having the crown mounted on these abutment posts. I was charged by my dentist $3450 for this crown to cover the implants in my mouth. Aetna has declined to pay any of this and says the less costly treatment would be a removable denture. You cannot place a removable denture over implants. Before I started this entire procedure we were told that the procedure was covered at 60%. Aetna is now saying they have the right to change this and cover a less costly treatment.Desired Settlement: I want the bridge to be paid for with my remaining 2013 benefit balance of approx. $1150. These are very deceptive practices which should not be allowed.

Business

Response:

Thank you for your inquiry received on February 10, 2014. Our [redacted] Team researched your concerns, and I would like to share the results of the review with you.

Review: Though I did not disenroll from the insurance, I received dis-entrollment letter. I contacted AETNA on the same day to resolve issue. I spent over 1.5 hr on the phone and no one tried to resolve issue. I was told that they cannot help me. According to the letter, there is an paragraph stating that if I did not disenroll and the letter is a mistake, I could call the provided [redacted] AETNA is clearly violating all of my right as a consumer by disenrolling me without my consent as well as not helping me to resolve the issue. Please help me with this matter ASAP. My member ID number is [redacted]. According to the letter, I have till the end of March to re-enroll. As of right now, I do not have any health insurance.If you can kindly help me with this matter, I really appreciate it. Sincerely,[redacted]Desired Settlement: DesiredSettlementID: Other (requires explanation)

Re-enroll my membership because I did not choose to dis-enroll. AETNA dis-enroll me without my consent.

Business

Response:

Thank you for your inquiry received on 03/19/2015 regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: I signed up for [redacted] and Aetna was the provider I selected. Well back in November I paid my premium, then they decided to take over 380.00 out of my checking account without authorization. They admitted this mistake and refunded me all but one month premium. When I called to question that, he said he could either send it to me or I could apply it to the December payment. I said apply to the December payment. But then in November they canceled my insurance without cause and refuse to refund the premium that would have carried me over into January 2016 had they not canceled my insurance. I want to know why they canceled and why they are refusing to refund December payment.Desired Settlement: Refund of premium

Business

Response:

Hello,

Thank you for your inquiry, regarding complaint #[redacted] Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Upon receipt of the complaint we immediately reached out to our Premium and Billing department to have the member’s concerns reviewed. We were advised that the member was not terminated for nonpayment; she was terminated for no longer being eligible by the [redacted] Exchange. The member would have received several letters from the [redacted] prior to the member’s termination. Aetna has no control over the policies that are created under the [redacted] Exchange; we are strictly administrators of the member’s plan. Aetna has no control over a member’s termination.

The member was drafted two months in error for November’s premium due to a system error. A refund was issued on November 06, 2015, for the $174.35 that was withdrawn in error. The member’s plan was terminated correctly per information received from the Marketplace. If the member is wishing to dispute the termination she will need to contact the [redacted] to inquire why her plan was terminated. I sincerely apologize for any inconvenience this has caused the member.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. [redacted] concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Thank you,

Ashley S.

Complaint and Appeal Consultant

Executive Resolution Team

Review: Before December 17, 2015 I called the [redacted] to by make them aware of my financial situation. I told them I was no longer employed. After they calculated my future income they told me I was exempt for now from having to purchase health insurance until my employment status changed again. They even gave me an exemption number to keep so could give it to the company that prepares my taxes. I spoke to Aetna before this happened and they told me my plan was going to change. After December 17, 2015 I received a letter from the [redacted] of these changes. On December 21st, 28th, and 29th I called numerous times trying to get through to a representative of Aetna and wasn't able to get through. I wanted them to also be aware of the change so they wouldn't withdrawn from my bank account. So I emailed Aetna on the 29th of December 2015 and January 2nd of this year. It took literally 3 days to get a responds with the run around saying what day did I want to cancel. Then I replied December 31, 2015 of course and it took 3 more days which I finally received another email saying sorry for the delay, and that if I could attach all the previous emails and send it again. Which was basically saying for me to tell them my story from the beginning since the previous employees didn't. So basically passing the buck around. By that time they had already withdrawn from my bank account $248.42 which I did not consent to them doing. First of all, I am not employed and nor do I have the extra income to pay my bank for overdraft fees. So what I am basically saying here is that they stole from me. Imagine the bid they have put me through at this point of time in my life situation. I had been a customer with Aetna Insurance off and on through my employers since 2004. So to be treated this way was just wrong on their part.Desired Settlement: I would like a refund sent to me by certified funds right away. I would also like to suggest if they are so busy now they should naturally hire more manpower. There are staffing company all over the United States to do so. Customers do not want to hear excuses for responding late. Customers want to hear solutions to issues nothing else. I would like to receive an email from them as to when I will be getting my money back.

Business

Response:

Hello,

Thank you for your inquiry, regarding complaint #[redacted] Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Upon receipt of the complaint we immediately reached out to our Eligibility department and requested the policy be terminated per the member’s request as of December 31, 2015. Our records indicate that the policy reflects terminated as of December 31, 2015, and we have also approved the premium refund. Please allow 2-3 business days for the $248.42 refund to be electronic deposited in the member’s bank account.

Please accept my apology that we did not provide the level of service that you rightfully expect and deserve, and my assurance that your concerns are getting the highest level of attention at Aetna. I would also like to thank you for sharing your experience with us. It is feedback like yours that helps us address issues and prevent them from reoccurring.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]

Thank you,

Ashley S.

Complaint and Appeal Consultant

Executive Resolution Team

Review: On March 1 2013, I had [redacted] surgery. Before the surgery, I completed the needed paperwork for Aetna two weeks prior to the surgery. My surgeon completed the paperwork, sent in copies of my MRIs, and he stated that my rehab time would take at least 6 months before I can return to work. During this time, Aetna told me that I was approved for short term disability. At 6 weeks post-op MD appointment, my surgeon wrote a letter to Aetna that I was not able to return to work until Sept 1st. Two weeks later, I received a letter stating that my short term disability was canceled and that my work rejected my medical leave and canceled my benefits because my short term disability was canceled. Aetna stated that the reason for this is because they did not receive "the needed paperwork" and that the MD letter was not sufficient. In May 2013, again, I turned in the same paperwork as I did in Feb 2013. In July 2013, Aetna sent me a letter stating that they were missing the letter stating that I'm appealing their decision. I sent them an official letter that I'm appealing their cancelation of my short term disability. Now, at the end of August, I have yet to receive word on my appeal and I am unable to return to my physical therapy sessions because my insurance benefits have been canceled. I have not received any short term disability income since April and I am not able to return to work until my physical therapy has been complete. Each time that I call Aetna, I am told that the person I need to speak to is not in the office. This happens at all times during the day. In the meantime, my family is suffering from loss of income and no insurance benefits.Desired Settlement: I want my appeal to approved so that my insurance benefits can be reinstated. Once this happens, I can return to the physical therapy sessions which will allow me to return to work once I am no longer on weight restrictions. Also, I want the short term disability income that I have not received for 4 months to be reimbursed.

Business

Response:

Thank you for your inquiry received on August 27, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to the Disability department for assistance with the member's concerns. They advised based on the review of the medical information and job requirements, it was determined that disability was supported from February 25, 2013 through February 28, 2013 and from April 26, 2013 through July 2, 2013. Therefore, Short Term Disability (STD) benefits have been reinstated effective February 25, 2013 through February 28, 2013 and from April 26, 2013 through July 2, 2013. However, it was determined that there was a lack of medical evidence to support disability effective July 3, 2013. As a result, STD benefits are denied effective July 3, 2013, onward. Also, STD benefits are not payable from March 24, 2013 through March 30, 2013, May 27, 2013 and August 3, 2013, since the member received vacation and holiday pay for those days. The Disability department provided this information to the member by letter, dated September 4, 2013, with appeal rights information.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the chance to address these concerns. If you have any more questions about this particular matter, please contact the Executive Resolution Team at [redacted].com.

Review: I have been working at my job for 3 years paying Aetna, my insurance for short term disability. The beginning of this year [redacted], and was told by my HR assistant manager that my short term disability will pay me for being off for [redacted]. After faxing the Aetna company the same exact documents TWICE because they had missed placed them the first time, they told me that my claim had been denied. They told me that I had not been paying them premiums when I was off of work, [redacted]. No one had told me that my insurance was cancelled or that I had to pay due to the fact that it came out of my paycheck automatically. So now they will not pay me my short term disability for being out of work after having a [redacted] for 6 weeks. So why have I been paying the money from MY paycheck for the last three years for them not to do their only job? I do not understand how they could deny me short term disability for something that they had not told me. They did not tell me that I still needed to pay them when I was off [redacted], who would have thought?

Desired Settlement: Refund I would like to recieve my short term disability pay as I was supposed to get. I would also like them to cover my doctor bills for [redacted], due to the fact that they (unknowingly to me) cancelled my insurance when I had taken time off to [redacted]

Business

Response:

Business Response /* (1000, 5, 2013/08/06) */

Thank you for your inquiry received on July 23, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to the Disability department and Strategic Resource Company (SRC) for assistance with the member's concerns. The member had a complete gap in coverage from February 23, 2013 to June 9, 2013. Based on the Enrollment Kit for this client each payroll deduction pays for coverage for one payroll period. If they miss a payroll deduction after coverage has begun they will not have coverage during the time that payroll deduction would cover unless they pay the full missed premium directly to SRC. The missed premium payments will always be applied to the oldest gap in coverage within the last 45 days. The claim was correctly denied. The Short Term Disability (STD) claim would only be considered if the member was taken out for a medical reason before her [redacted]; however, a medical reason was not shown on the STD paperwork. Ms. [redacted] had no coverage for the STD or the other elections during dates February 23, 2013 through June 8, 2013.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the chance to address these concerns. If you have any more questions about this particular matter, please contact the Executive Resolution Team at [redacted].

Review: My company canceled our Aetna dental insurance on 12/31/2012. Aetna continued to bill us after that date and our accounts payable department accidentally paid two month's of premiums before the error was caught. I called Aetna on June 21, 2013 to complain. Spoke with a woman who assured me all future billing would cease and that our biller would contact me about our refund within 5 business days. She never called and I got another bill. On July 10, 2013 I called back and spoke to a different woman who also assured me we would receive no further billing and that our biller would call me in 5 business days. She never did. I received another bill so I called again and was told the matter was only sent to billing on July 18, 2013 for manual adjustment and that it takes 5 - 10 days for processing. I am very disappointed in the way this has been handled by Aetna; I would not be inclined to use them for business or personal insurance in the future nor would I recommend them to anyone asking my opinion.

Product_Or_Service: Dental Insurance

Order_Number: n/a

Account_Number: Account # XXXXXXXX

Desired Settlement: Aetna owes my company $850.60 and I would like that money refunded promptly. I would also like them to stop billing me for additional premiums since we no longer have their dental coverage.

Business

Response:

Business Response /* (1000, 5, 2013/08/13) */

Thank you for your inquiry received on July 30, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to the Aetna Small Group Sales Support Team for assistance with the member's concerns. They advised that a manual credit adjustment of $1275.90 was requested for the group since the system did not generate credits upon termination effective December 31, 2012 that reflected in April 2013. Also, an immediate request for a refund of $850.60 was submitted and once approved will be sent as urgent. We apologize for any delay and inconvenience this has caused.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the chance to address these concerns. If you have any more questions about this particular matter, please contact the Executive Resolution Team at [redacted].

Review: I Have [redacted] insurance through AETNA through my employer.on June 5 2015 I was admitted to the Hospital [redacted] in [redacted]. I needed to have [redacted] immediately. I submitted my claim during my absence from work and all supporting documents. Hospital admitted to and discharge date along with what was done and the recovery time. Aetna has continually sent be letters saying they need more information which I supplied all that I can the doctors names addresses and fax numbers for anything else they need. Being that I see all these docters regularly I have asked if they returned any request from Aetna and they claim they have not received any request for information. Both the Cardiologist as well as the surgeon ar new Doctors are new to me never saw them before my illness. once again I receive a letter than I need to gather information and submit it to them. Really?i am recovering from [redacted] and they cant get this verified and any supporting document sent to them via the phone, I supplied my primary care doctors number and address. meanwhile im not getting paid and there is no since of urgency in getting this claim paid out for the weeks past .Desired Settlement: DesiredSettlementID: Not applicable

I want the Company to do their job an gather the information they need in a timely fashion ,so I can get my claim paid out so I can pay my bills until I get back to work.

Business

Response:

Thank you for your inquiry received on 07/10/15 regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Every time we go to the doctor our primary physician calls aetna to see if we need a referral or a precertification. Every time they are told that we dont need either. So we go to the hospital who sees us because they too believe we dont need a referral or a precert. Without fail we then get a bill giving some excuse as to why they paid at the lower amount....either we need a referral or we need a precert even though we have direct access and dont require one. Further, we were told be a SUPERVISOR to just get a referral for everything even if we dont need one so if Aetna processes it wrong then we dont have to worry. THEY GIVE INCORRECT INFORMATION CONSISTANTLY AND DO NOT CARE. FURTHER THEY CLAIM THEY ARE NOT RESPONSIBLE. Also everytime you call them they act like they have no idea what you are talking about.

Review: I sent an appeal to Aetna concerning the information the insurer providing me for a CPAP machine. Aetna provided Sleep Management Solution a quote for the medical equipment ($34) and a monthly charge ($5). Aetna process the claims correctly for some months, but not for others. I called several times to have the claims corrected, which they did; however, a call I made July of 2012, resulted in Aetna stating the coverage needed to go against my deductible. This resulting my out of pocket going from less than $100 dollars to over $800. As I understand now, my medical coverage requires medical equipment to go against deductible prior to coverage picking it up. This information was not provided to me 8 months earlier when I evaluated my options. Their response to me was it was a "misunderstanding". This is just not acceptable, as I had made several calls, claims were processed as quoted and to go back on what they provided me and Sleep Management is just poor service, resulting in a significant financial commitment I did not plan for or probably would have made a different decision.Aetna should bare some of this financial due to their poor service. I would understand if this was a 1 time miscommunication, but this was quoted and processed as it was quoted. Even phone calls resulted in claims getting corrected. I want Aetna to do the right thing.Regards,[redacted]

Desired Settlement: I would like 1/2 the cost reimbursed, $400.

Business

Response:

Business Response /* (1000, 5, 2013/04/24) */

Thank you for your inquiry received on April 19, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to the Claims department for assistance on the member's issue. When the claims for the sleep study, equipment and the rental charges were first received, the claims were processed at the out-of-network benefit level in error and applied to the out-of-network deductible. They were reprocessed at the in-network level. There were claims that were received and processed at par level before the out-of-network claims being reprocessed, so those claims were not applied to the deductible as it was already showing met due to these claims.

Once the error was discovered, the first few claims were reprocessed at par level, then the deductible was no longer met, so a few more claims were reworked correctly per the in-network level of benefits with the amounts going to the deductible. As the rest of the claims came in for dates of service from June through October, these were processed correctly the first time and applied the amounts to the deductible.

Unfortunately, they did not see any documentation on the file that the member or the provider was told that the deductible wouldn't apply to Durable Medical Equipment (DME) before the services being rendered. They did see a provider on January 16, 2012, use Aetna Electronic Data Interchange (EDI) system for benefit information, but they cannot tell which provider called and what benefits were given, since the provider didn't speak to a representative. We do apologize for the inconvenience; however, no exception can be made at this time.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the chance to address these concerns. If you have any more questions about this particular matter, please contact the Executive Resolution Team at [redacted]com.