Aetna, Inc.

Review: I am 22 years old and in September of 2014 I had my [redacted]. I have my Medical Insurance through [redacted]. I had no idea until I received a collections notice from the Anesthesiologist that there is a supplemental coverage through Aetna Insurance. I was told I must contact Aetna to remedy the issue. I called the Customer Service line and received no help, only given another number [redacted] to call. Called that number and apparently that is only an employee number of someone who would work for [redacted]. No help. Called back the customer service phone number and requested a Supervisor. Agent insisted on account information and the only information I have is an account number of [redacted]. I don't know who owns this account or why I'm on it? I have never approved or signed anything approving Aetna Insurances? No one is helping me resolve or even giving direction on how to. I requested a Supervisor again. I was told no. I persisted.... The agent put me on a very long hold to note the account, then finally came back on the line to inform me that she NOW was going to transfer me to a Supervisor. She purposely transferred me to a Supervisors voice mail of one that was out until February. Called back. Again asked for Supervisor. Told no again. Wanted account info that I don't have. Asked to have Corporates number and this agent refused. Again requested anyone above her and she said no and going to disconnect call and hung up. Called back again. My frustration is now at peak! Every time I get an agent on the phone and no matter what tone or words I use, I could not get to a Supervisor, Manager or even a Corporates phone number. Terrible Customer Service and I'm to be held accountable for a bill that should NOT be my responsibility! I am looking for resolution or even direction on how to resolve. I have no idea who put me on this or why I'm at all involved with this medical Insurance? Please assist in having someone with authority and real knowledge call me.Desired Settlement: As stated above, I would like this resolved or even to talk with someone of authority and real knowledge to help resolve this.

Business

Response:

Please see our response to the complaint #[redacted] for [redacted] received on January 15, 2015.

Review: I went to doctor for preventive visit (annual physical checkup). Our company policy for adult Preventive Care Routine physical exam states that "In Network: 100% covered, no copay/no deductible; includes lab & x-ray;..." My doctor did an x-ray on me and submitted the bill with routine code per the policy provided by Aetna. However, Aetna declined the 100% coverage as specified in the quoted company policy above. The medical bill showed up with charge for copay ($20) and x-ray ($72.20). I am sure that those should be covered by Aetna. I tried to resolve this with Aetna directly and have exhausted the appeal process through Aetna. I have been very disappointed by their response, which just kept avoiding the policy statement and just declined the coverage.Desired Settlement: I would like to request the fulfillment of the full coverage (100%) for x-ray during the annual physical checkup. I have not paid the medical bill yet so Aetna should pay the medical bill.claim id: [redacted]The service date is [redacted]The total liability should be $92.00

Business

Response:

Thank you for your inquiry received on November 4, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: Last month, Aetna deducted more than 3 months premium. I had to call them and was told the amount was deducted in mistake. I finally called my bank to not pay that and paid Aetna the correct balance. In March '14, they have again deducted more than 2 months premium without sending me an invoice EVER.Desired Settlement: I want the extra amount refunded AND Aetna to pay any and all charges imposed by my bank due to a unreasonably large transaction exceeding my current balance. I also want Aetna to correct my account to deduct the proper amount next month onwards.

Business

Response:

Thank you for your inquiry received on March 3, 2014. We reached out to the Individual Billing and Enrollment department for assistance with the member’s concerns. They reviewed the account and the member opted to set up his account on Autopay. In these cases he will not get an invoice. They are billing him correctly as his first payment was returned as NSF, so the system will continue to bill for the full amount due. If the member wants to get invoices, the member may terminate the Autopay and pay by a different method. At this time, there is no refund due and they would not be able cover overdraft fees as the member chose to initiate the Autopay himself.

Consumer

Response:

Review: [redacted]

I am rejecting this response because:

I only authorized auto-deduct for amount properly due. For 2 months in a row, Aetna has attempted to deduct more than 3 months premium, even though I only have one months premium due. For example, last month they attempted to withdraw $1497, when they should have deducted $930.42. Again this month, they have deducted $1031.58, when the correct amount due is only $448. Calling their customer service is of no use, because the agent always says the amount due is much lower than what auto pay is deducting and they don't know why the erroneous deduction happened, after making us wait 70-90 mins on the phone. They never get back.

Sincerely,

Review: Aetna refused to pay my Dental claim on 06/03/2015. It was not made clear to me at any point that I would have to wait a year for major dental work. in addition to this Aetna contends that I should wait and jeopardize my safety health and my teeth to wait for their time period to elapse. I wanted to give them a chance to do the right thing before I make it public-ally known they do not care about their customers safety over their bottom line and unfair stipulations in their policies.Desired Settlement: Pay their $651 portion of the dental claim as that is the whole point of having dental insurance. I do not want to have to involve a lawyer because Aetna failed to consider human safety and general well being over their bottom line.

Business

Response:

Hello,

Thank you for your inquiry, 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.

Upon receipt of the complaint we immediately reached out to our Claims department to verify if the claim was denied correctly. We were advised that the member was within the waiting period of 12 months to have any Type C Services dental work done and the claim was denied correctly.

As stated in the Benefit Plan Booklet-Certificate:

Your Effective Date of Coverage With respect to Type A and B Services, your coverage takes effect on the later of:

-- The date you are eligible for coverage; and

-- The date you return your completed enrollment information.

With respect to Type C Services, if you are then in an Eligible Class, will be the Effective Date of this Plan. Otherwise, your coverage takes effect after 12 months of continuous service under the Plan.

Type C Expenses: Major Restorative Care

...

Inlays/Onlays

...

Our records reflect your original effective date is October 1, 2014, with a 12 month waiting period. Since this criterion was not met, benefits are not eligible under the plan for the service performed June 3, 2015. Unfortunately, your claim was denied based on your plan's limitation on Type C dental work; therefore, we are unable to pay your claim.

Aetna does care about the safety and health of our members and I empathize with your situation. While we understand your concerns and recognize this is not the resolution you sought, our decision remains unchanged. Our actions are solely guided by the plan guidelines in order to administer fairly and equitably to all participants. We have attached the member's plan documents which explains the coverage waiting period.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [redacted]’s 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

Consumer

Response:

Review: [redacted]

I am rejecting this response because:Basically this was a necessary procedure to fix my Dental onlays so my teeth don't rot out of my mouth. That is like saying that you have a bullet wound but need to wait to have it removed because your insurance wont kick in until next month. This is a MAJOR safety and health concern that it is not something that could wait until October. I find it Extremely unethical to reject a claim based on something procedural where safety and ones health is concerned. And again this was just trying the ethical approach before calling Aetna out on Social and mass media for caring more about their policy regulations than my health and safety of my teeth. It is in Aetna's best interest to pay the claim that they should have covered because my teeth are more important than some rider in a unfair policy. Several contacts Media outlets expressed interest in the story and will consult a legal advisor on the best course of action to pursue next. Exactly how much business are the willing to loose over this issue ?

Sincerely,

Business

Response:

Dear Ms. [redacted],

Please see our response to complaint #[redacted] for [redacted] that was received by us on October 08, 2015.

The records indicate that Mr. [redacted]’s original effective date is October 1, 2014, with a 12 month waiting period. Since this criterion was not met, benefits are not eligible under the plan for the service performed on June 3, 2015.

We had the claim verified with our Dental department to review if there was any way any exceptions could be made; we also reviewed the original appeal information. However, our decision remains the same. Based on the guidelines of Mr. [redacted]’s policy that were provided in our previous response, the plan has a 12 month waiting period for type C services. The service performed June 3, 2015 was a type C service. Therefore, an exception could not be made. Our actions are solely guided by the plan guidelines in order to administer fairly and equitably to all participants.

I apologize for any difficulties this situation has caused Mr. [redacted]. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [redacted]’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted].

Regards,

Julian C[redacted]

Executive Resolution Team

Consumer

Response:

Review: [redacted]

y.

I am rejecting this response because: Regardless of their policy there should Always be exceptions when it comes to NECESSARY dental work. Basically I feel Aetna has put their policy before my Health and safety. Was I just supposed to wait for their 1 year deadline as my teeth rot out ? I appealed through Aetna and they rejected that appeal. and I just wanted to give them ample chance to repair the situation before going to less preferable means and causing negative publicity and cost much more in the long run but if that's that it takes to get them to do the right thing so be it.

Sincerely,

Review: Aetna has repeatedly denied claims for insurance coverage. They've gone so far as to even tell doctors that I am not a member of Aetna, then lie and tell me that the claims from the doctors were never made.Desired Settlement: I want Aetna to cover my in-network medical expenses.

Business

Response:

Hello,

Review: Have to call every month and fight to get my infant's medication approved, even though there is a letter on file stating it has been approved for a year. This letter is dated January 8, 2013. Yet, I have to call and spend hours on hold fighting for approval.

Desired Settlement: Approve the medication so I don't have to fight each month!!!!

Business

Response:

Business Response /* (1000, 11, 2013/07/26) */

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

We reached out to our Pharmacy department for assistance with [redacted]'s concerns. Since Ms. [redacted] is not covered under the plan, they did try to contact Mr. [redacted] on several occasions; unfortunately, the call was transferred to his voice mail. Our Pharmacy department will try on Monday, July 29, 2013 to contact Mr. [redacted] directly; or he may reach us at the below email address.

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].

Business Response /* (1000, 14, 2013/07/31) */

Thank you for your inquiry received on July 1, 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 Pharmacy department for assistance with the member's concerns. The issues with the authorization were corrected and the Pharmacy department has reprocessed. We apologize for the delay and inconveniences this has caused the member.

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].

Business Response /* (-10, 17, 2013/08/01) */

The Pharmacy department also advised that the member was trying to get the drug from [redacted]. An authorization has been entered for 1 year (until July 25, 2014). This will allow the drug to continue to process on a monthly basis until that time. After that date, a new authorization will need to be entered.

The Pharmacy department contacted the member's pharmacy and they reprocessed the June claim and indicated they will refund the member upon their return to the pharmacy with the receipt. The July fill has also been processed and is being prepared for the member.

Aetna Pharmacy department has been trying to contact the father numerous times to let him know the medication can be picked up and our systems have been updated.

Consumer Response /* (2110, 18, 2013/08/01) */

(The consumer indicated he/she ACCEPTED the partial settlement response from the business.)

It is sad that a Revdex.com complaint had to be filed for an action to occur when I had contacted the business personally on numerous occasions. Since the result I wanted was for medicine to be approved on a monthly basis I can not state whether the result was conclusively resolved for another month.

Review: Aetna is the provider of health insurance offered to students at [redacted] University. Health insurance is required of undergraduate students, but is optional for graduate students. There is a provision in the policy that charges students (consumers) a $100 penalty for seeing their primary care doctor without first obtaining permission (via a referral) from the university. This provision is a deviation from the terms of most health insurance plans. Because it is a deviation from standard health insurance terms, this requirement should have been clearly disclaimed in both the health insurance brochure and full policy provided to students. The Aetna brochure and policy do not indicate that this referral requirement is applicable to primary care doctors. No reasonable person would be on notice that such a requirement was part of the policy. In most (if not all) other insurance plans, the primary care doctor is the one that writes a referral. For this policy to be valid, Aetna was required to explicitly disclaim it, so as to adequately put students on notice of the possible penalty charge.

Product_Or_Service: Medical Insurance

Order_Number: Member No WXXXXXXXXX

Account_Number: Plan XXXXX XXXXXXXXX

Desired Settlement: I would like my $100 refunded. I would also like the policy and brochure to be revised so that the referral requirement is explicitly disclaimed to other students (consumers). It should be specifically stated that a referral from [redacted] University is required to see any doctor, even a primary care doctor, to avoid the $100 penalty. It is recommended the text be larger, in all caps, and red to be legally valid.

Business

Response:

Business Response /* (1000, 5, 2013/07/08) */

Thank you for your inquiry received on June 24, 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 Aetna Student Health (ASH) for assistance with the member's concerns. According to the member's plan brochure, under referral requirements, a referral from the Student Health Center (SHC) is not a requirement; however, the deductible amount will be waived when services are provided at the Health Center or when a referral is made by a Health Center Doctor. The office visit for March 11, 2013, was not a routine visit. She did not have a SHC referral, so the deductible is not waived when there is not a referral. Unfortunately, the deductible requirement stands according to the plan provisions.

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].

Review: The health care plan I have with Aetna represents that preventive care is 100% covered, no co-pay required. However, when I went to my doctor for my annual well woman visit and she ordered a routine, preventive HPV test, Aetna would not honor their 100% coverage for preventive care, I was required to later pay my co-pay becasue they do not consider the test preventive. I believe this is false advertising, at best, and that my doctor is the only person who would be able to determine the test as preventive or otherwise. If a doctor is ordering a routine test during a preventive care visit and coding it as preventive care, I do not see how it can be considered anything else.

Desired Settlement: Aetna should pay the co-pay they have refused to cover.

Business

Response:

Business Response /* (1000, 5, 2013/04/23) */

Thank you for your inquiry received on April 9, 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 with the member's concerns. The copayment was applied based on the cause of the member's illness submitted on the claim. The claim was sent back for reprocessing with a corrected diagnosis to be paid as preventive service. We apologize to the member for any delay and inconvenience.

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: It is beyond my comprehension how this company, who I have been insured with for many years, claims to have sent a letter to notify me of changes to my account, which was never received, and just dropped my policy without any proper notification or personal contact with me. On top of this, my insurance agent was never notified either. How does this happen??? I have called multiple times and so has my agent and the only answer we get is "We sent a letter by mail." This is not sufficient. If you are sending such important information, this should go certified mail with a return receipt. What kind of company can do this to a client who has always paid the bills and cancels a policy and insurance coverage without any warning or contact? I need answers. I have been on autopay for this policy since I enrolled, never missed a payment and only by accident found out one day out of the blue that I had no coverage for the past 6 months. I am beyond disappointed with Aetna and how they neglect to handle this situation. I have since then had to restart a new policy at a much higher premium and different benefits. This is not right. I should have been properly notified and I should have been given options to renew my policy and not just left off in the deep end.Now, for the second time my insurance coverage was dropped, and they decided to put me back on my old plan( again without my knowledge or consent) and want me to pay $1,946 in premium for the time I was not covered to have this plan reinstated. I never asked for this and I didn't have insurance coverage so why do I owe money for a time I didn't have coverage? This is absurd, unprofessional and I need answers.Desired Settlement: I would like to be on my old plan, which both my doctors are on, and not be responsible for paying Aetna for a 6 months of back-dated premiums in the amount of $1,946 for not being covered.

Business

Response:

Thank you for your inquiry received on 06/04/2014 regarding complaint #[redacted] for J[redacted]. 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 Individual Billing department for assistance, and the member stated that she never received the Repurchase letter last year and was upset that her policy terminated as of 12/31/13. She applied for and was enrolled under the [redacted] effective 05/01/14, but that policy was voided (per member request) since several doctors were not covered by that plan. As an “Exception” to the member, we allowed her to go through with the repurchase of her old plan. This was processed in April. The repurchase is retroactive to 12/01/13, which means the member owes the difference in premium for December (since the rate increased with the repurchase) and the premiums for all months after. We are not going to waive all premiums from 01/01/14 to 05/31/14. The member is responsible for making those payments and may have any claims during that period resubmitted. If no payment is received, the policy will be terminated.

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].

Consumer

Response:

Review: [redacted]

I am rejecting this response because:

Review: I am trying to cancel the Aetna international insurance coverage provided by [redacted] wich operates globally as http://www.aetna.com/They refuse to cancel my membership and continue to charge me $183.21 per month. I sent cancellation request form , called the phone number ( ###-###-#### ) that [redacted] from ###-###-#### provided and left the message. You dont get to speak to anyone. You can only leave message for some lady [redacted]. I am not getting any response. Even their cancellation request says that you can cancel only within 14 days of coverage which seems completely illegal. See this please . [redacted]We have been with them for 6 months and do not need any further coverage from them.I need to cancel the coverage and any further charges.Member id is [redacted]Desired Settlement: Cancel the coverage and charges immediately!

Business

Response:

Thank you for your inquiry received on April 17, 2014. We reached out to the Aetna Global Benefits (AGB) department for assistance. Unfortunately, they were unable to find this member. If possible, please supply additional information such as a member ID number, usually beginning with a “W” or a social security number. Thank you.

Consumer

Response:

Details of Coverage

Customer Name: Mr [redacted]

Policy ID Number: [redacted]

Effective Date: October 01, 2013

Location: [redacted]

Product: [redacted]

Policy Type: [redacted]

Monthly: 1st monthly payment of $183.13 and the 11 subsequent monthly payment of $183.21 (total annual amount 2198.44)

Sincerely,

Business

Response:

Thank you for the information submitted. We again reached out to the Aetna Global Benefits (AGB) department for assistance. Unfortunately, they need the member ID number that is located on the member’s ID card. It would begin with a “W”, followed by 9 digit number or they need a social security number in order to further assist the member. We do apologize for the delay and inconvenience. Thanks.

Consumer

Response:

Review: [redacted]

I am rejecting this response because:

This is beyond ridiculous! They dont even now where to find me and in what system to look.

Review: I have been trying for several months to get reimbursed by Aetna for a pharmacy prescription dating back to January 2013. Despite mailing and faxing my receipts several times, Aetna has so far been unable to complete the reimbursement even though over the phone they tell me that the charges are reimbursable. They have the paperwork in their system, they just cannot seem to cut the check to make the reimbursement.Desired Settlement: I want the missing payment of 69.99 less copay refunded to me immediately. I would also like a call from a C level executive of Aetna apologizing for the inconvenience, and for Aetna to send my wife flowers for the inconvenience caused by multiple phone calls to well meaning Aetna telephone staff who were unable to help us.

Business

Response:

Thank you for your inquiry received on 02/12/2014 regarding complaint #[redacted] for [redacted]. Our [redacted] Team researched your concerns, and I would like to share the results of the review with you.

We reached out to Aetna's [redacted]) department for assistance, [redacted] advised there is no claims on file for [redacted], his spouse, or his dependent for the date of 01/18/2013 for $69.99, as stated in his complaint. We attempted to reach out to [redacted] for additional information, but were unsuccessful. If [redacted] could advise of the name of the medication, correct purchase date, and which member the prescription is for, we can then review his issue further.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted]'s

concerns. If you have any additional questions regarding this particular matter, please contact the [redacted] Team at [redacted].

Consumer

Response:

Review: [redacted]

I am rejecting this response because: They are mistaken. I have in front of me a copy of a denial for 69.99, from Aetna, with no explanation. I cannot believe that your system has no record of this, as it shows up in my Aetna online account.

I do not wish to put the personal medical details in this Revdex.com system due to privacy concerns, however I will send an email to the address indicated.

Review: My doctor [[redacted] sent in a prescription on Jan. 30 2015 for a three month stateing the dose of 20 units in am 20 units at noon 24 units at supper as daily doses. They sent me a 70 day supply. They say that is what the doctor wrote. Also note that I only have 3 refills till 02/17/16, the same as the other 6 or 8 meds. I ordered at the same time. I would like to get the 20 days of my meds.Which I was auto billed for [3 month worth]. The Rx number is [redacted]I HAD TO TYPE OUT THE * SO IT WOULD NOT THINK IT WAS A SSN]p.s. I have a phone number and web name [redacted]Desired Settlement: Get my meds. as my doctor ordered. Without and charge to me, since I already was auto billed for 3 months.

Business

Response:

Hello,

Review: I signed my son up for a trip to go to [redacted] for June of 2014. The account is [redacted]. Circumstances happened and my husband lost his job. I submitted all the required paper work that was requested after there was miscommunication the first time that I needed to cancel the trip, back on January 24, 2014. And was told it would take 30-60 days for a decision. I then was calling for updates because I never received any correspondent or email or even phone calls to let me know the status. I finally called in one day and they stated that my claim was denied.(I didn't receive anything in the mail or email, or phone call. so if I didn't call I wouldn't had even known) I was then told I needed to file an appeal, which I did and was received April 9, 2014. I was told that it would take another 30-60 business days for the appeal, it is now July 22, 2014. Which I last called on 7/21/14, and I was told that my case is still under review. This has been going on since January 24. Almost 7 months later and I'm still waiting. The account that I'm referencing is [redacted].Desired Settlement: I would like the $500 refunded, that I'm entitled because under their own rules they say if loss of job is a reason, I would be refunded.

Business

Response:

Thank you for your inquiry received on July 22, 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: Hello, In July 2013, I received an authorization for a vacation supply of month of my prescriptionUpon retrieving my RX, the pharmacy charged $251.99, instead of my $co-pay which would have been $They said is was due to the insurance filing my RX as a Brand, when in fact is was GenericI contacted Aetna and was advised to file a personal claim, which I promptly did a week later in AugustI contacted them a week later and they told me it was approved and I should received a refundI have yet to receive my refundIt has now been monthsMy patience is at an end after going above and beyond patience with rep after rep informing me that a check had been cleared for payment, and despite my requests to numerous customer service representatives in Oct, Dec, Jan, Feb, and Mar of to speak to an authorized supervisor, I was given a complete run-aroundOn March 7, 2014, I was finally able to obtain a supervisor after having to be very rudeHe said he would check on the back end and call me backWhile on the phone he said he called my pharmacy to get receipts (which they should have already had given numerous reps told me a refund was being processed) He said it takes days to process and it has been daysI now demand my entire original amount of $be issued to me within days as I feel the $copay is more than enough to cover the months of hassle I have had to deal with Aetna on a constant basis to receive a minute sum considering the amount of money they have to cover this claimPlease email me and I can provide my Identifications numbers and a reference number for the file they have set up on thisSincerely, [redacted]Desired Settlement: I wish to be refunded my original amount of $within days to the address below:[redacted]
Business
Response:
Thank you for your inquiry received on April 2, 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 Pharmacy department for assistance with the member’s concernThey advised this case is still being worked on by [redacted] to fully resolve for the memberThis issue was escalated as high priority to have it resolved and the member reimbursed urgently
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address these concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]
On 04/22/2014, the following information was documented:
The claim has been reversed and reprocessed and the member will receive a reimbursement of $
We apologize if this information was not submitted to Revdex.com as a resolution to the member’s complaint within the timeframe allowed
Consumer
Response:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me
The complaint was finally handled when I posted on their [redacted] page, and the rep [redacted] (who should be commended for handling this in days versus everyone else that took a year) had a check issues the next day to me despite the fact he Pharmacy Supervisor said it has been mailed days prior, but the check was cut after she took the time to escalate it and send the check immediatelyI have received the payment thanks to her diligenceI suggest that these departments initiate a better form of communication within call centers and ones between supervisors and customer service repsIt seems if you want better service, the Social Media Department is the better choice
Sincerely,

Review: On Feb. 18, 2015, my wife had surgery. For several months after that, Aetna said that I am not responsible for the bill. But the hospital's billing dept would keep calling me and threaten that my bill would go into collection. Aetna simply would say that I am not responsible and that the hospital did not send pre-certification paper work in time. So here we are at the end of 2015 and the hospital still wants payment. The hospital said I was denied coverage and I need to pay but Aetna's website still tells me I am not responsible for the bill. The hospital said that I should appeal the outcome, but Aetna has told the hospital that they will not overturn the "appeal" I am confused. Either Aetna should be clear and tell me not to pay or pay the hospital directly.Desired Settlement: I would like Aetna to pay for my wife's surgery.

Business

Response:

Hello,

Thank you for your inquiry, 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.

Upon receipt of the complaint we immediately reached out to our Claims department to have the date of service reviewed. We were advised that the member is not responsible for the billed charges because the facility failed to call the Pre-certification department in a timely manner. We confirmed that both the member and the provider’s explanation of benefits (EOB) state that the member is not responsible for the billed charges.

The provider did not call our pre-certification office within one day of discharge, so it will be their responsibility to file an appeal, not the member’s responsibility. We called the facility and left a voicemail with the billing department explaining that they should refer to their EOB which states they are to not balance bill the member. It also went on to explain that claim was denied due to failure to follow Aetna contractual notification requirements. We advised of the address they could send the appeal request to and left a call back number for any questions/concerns. We have also mailed another copy of the explanation of benefits to the provider for their records.

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

Thank you,

Ashley S.

Complaint and Appeal Consultant

Executive Resolution Team

Review: I am trying to get several reimbursement claims resolved. I fax the reimbursement claims to the number listed on the claim form ([redacted]), after about 10 days I receive a letter regarding my claim stating that it has been denied. I call their customer service (and get transferred 3-5 times because there is no direct # to reach the reimbursement department) to explain that the claim should not have been denied and they tell me that they do not have access to the reimbursement claims that are submitted. I ask if I can speak to the department that can see my claim and customer service say no that they can send an email to that department and call me back within 72 business hours. I wait over five business days and have to call back again only to be transferred multiple times and be give generic answers that I need to resubmit my claim. I practically have to force the individual on the line to simply read the notes on my account to find evidence that the situation has already been escalated. On multiple occasions I have been able to get the agent to see the notes indicating that the claim has been resubmitted and that a mistake was made but each agent indicates that they cannot 'see' the claim in the system. Answer this question HOW CAN I HAVE A DENIAL STATEMENT W/O THERE BEING A CLAIM IN THE SYSTEM??? I have four denial papers with different dates on each. I have resubmitted claims with corrected information to only get the same result. This is an endless loop where I send forms and get the same answer that they cannot see anything in they system and yet I can still get information in the mail from Aetna about my claim. I want to be able to call Aetna to get the status of my claim. I want the agent to have direct access to the information I have submitted. I cannot understand how a multi-million dollar company can have such terrible customer service. I feel like it is Aetna's goal to keep giving me the run around about my claim to avoid giving me reimbursement for my pharmacy claim.Desired Settlement: I would like for Aetna to recognize their terrible customer service. I would like for Aetna to find my claim and make sure it is processed correctly. I would like an apology for all the time I have spent dealing with this process trying to get a resolution. At the end of the day I would like for my claims to processed and my money reimbursed for my pharmacy claim.

Business

Response:

Thank you for your inquiry received on December 05, 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 wife had a very rare ocular tumor which there was only one doctor in New York City that we could go to, according to the Ophthalmologist at [redacted] Ophthalmology. As this doctor was out-of-network from my in-network only Aetna insurance plan, I contacted Aetna and was told that I need to be "pre-certified" in order to have the services be covered. I went through the process, and the pre-certification was approved. As the doctor's policy was to have the patient pay the cost out of pocket and be reimbursed from the insurance company, I spoke with an Aetna customer service representative who told me that I would be covered for 100% of the services that I paid out of pocket. I do not remember the term she used, but she said there was a difference between being covered in-network with negotiated rates and being covered for out of pocket expenses and that I can rest assure that I would be covered for all costs out of pocket. On 10/27, I spoke to a customer service representative and was told that for my wife's appointment on 10/10 for which I paid $830 out of pocket, I was approved to be paid $399 back from Aetna. She said it was a mistake on Aetna's part and once I receive the check in the mail (as it will be mailed to me not the doctor), that I should then call back and have them reprocess the claim and I would receive the difference of about $470. As of 11/11/2014, I still have not received a check so I decided to call back and talk to another customer service representative named[redacted]. I was either on hold or on the line with [redacted] for 58 minutes on 11/11/2014.[redacted] told me that I am not eligible to receive anything back from the difference. [redacted] also informed me that my wife's surgery/biopsy performed on 10/22 is still under review for the $29,000 claim, but the preliminary amount to be paid back is about $1,500 but that amount is still pending and no one can help me until 12/1 when the claim is finalized. This difference leaves a shortage in total of about $27,650 (if my math is correct). [redacted] told me that his direct supervisor is out of the office today, but that he could try to have a supervisor to get back to me by the end of the week. I asked him if there was a corporate line that I could call to try and resolve this issue and he put me on hold and told me he would ask around but that phones were very busy and he did not think anyone would be available to give him that information. I was put on hold for about 2-3 minutes, and when he came back he said he would put me back on hold as he was still searching for an answer. I told him that I did not want to be back on hold and that I will just wait for a call back from his supervisor, or anyone that could help me, by the end of the week but otherwise I'd call back on December 1 when the claim was finalized. [redacted] really made me feel like I was an it and I could not believe that someone in "customer service" could talk down to a customer like that.Desired Settlement: In a perfect world, Aetna would be able to produce a recording of all calls between myself and their customer service representatives. This will show that I was told multiple times that anything paid out of pocket would be fully reimbursed. I do not know if they record and save all conversations between customers and reps, but I hope that they do. I also believe that an almost 6 week wait time is quite long for a claim to be processed, when I was told originally it should be about 7-10 days.

I believe Aetna should fully cover per the doctor's billing amount for any pre-certified claims.

Business

Response:

Please see our response to the complaint # [redacted] for[redacted] received on January 07, 2015.

Review: On or around June 7th, I was considering enrolling in Aetna through COBRA. This was because my mother had gotten laid off and I didn't have insurance access through my job. I wanted to know if my deductible would carry over, because at that point I had met $2734.45 out of the $3,000 deductible. One of Aetna's member-services personnel spoke with me on the phone on or around June 7th and said that YES, my deductible would carry over. Because she told me this, I made the decision to stay on Aetna via COBRA. And because of what this Aetna representative told me about my deductible carrying over, I did not enroll in my new job's insurance because I did not want to pay another deductible. Now, after using Aetna and racking up medical bills, I was just told by Aetna that in fact, my deductible DOES NOT carry over.Desired Settlement: I want all of my deductible to be carried over to my current plan (all $2,734.45 of it), just as your representative promised it would. And I want to be reimbursed for my medical bills that would have been covered after meeting the original deductible, since after I enrolled in Aetna through COBRA.

Business

Response:

Thank you for your inquiry received on October 9, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: Health insurer would not provide full plan brochure until AFTER sign-up. Forcing consumers to contract for services without knowing all of the terms.

I was researching insurance plans and found [redacted] (an Aetna company) on the [redacted] marketplace. There was a summary of the plan on the marketplace, but I wanted to compare the details of the actual plan's full brochure (usually a 100+ page document). I went to the company's website and again, the only available information was a plan summary (about 8 pages) and a marketing brochure (20 pages). I called the company to request this information. The company required me to provide my name, birthdate, phone number, and physical address before they could even transfer me to someone who could help. I explained that I felt uncomfortable providing personal information in order to view a plan brochure (I was still in the process of comparing insurance, I said, and once I decided on a plan I would happily provide everything on the member application). With no other choice, I provided the information. After being transferred 3-4 times, I was told that the company would not provide the plan brochure until AFTER I signed up with them. I asked them, did they realize their company is forcing consumers to enter into a contractual agreement without knowing all of the terms? This is a fraudulent practice. The company stated that "everything I needed to know" was in the plan summary, but this is outright false. There are details in the 100+ page insurance document that help me choose which plan is right for me, and I have a right to access that information before I enter into an agreement with a company. I should be able to compare those details between plans and among different companies before I choose which insurance plan to go with, because I am contracting for coverage for a full year and with the expectation that I will be spending at least several thousand dollars during that year. Please help consumers get access to these plan brochures as soon as possible. Withholding this information is a fraudulent practice that is hurting consumers.Desired Settlement: Correct the current, fraudulent practice and make full plan documents (detailed plan brochures) available on the company's website or at the very least, upon request. Other insurance companies have full insurance plan documents readily available on their websites.

Business

Response:

Thank you for your inquiry received on December 15, 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.

We reached out to our Enrollment department for assistance; please accept our sincere apologies for any difficulties that were encountered with our website and or representatives. It is our goal to provide quality service and regret any incidents that created the perception that we have not provided Ms. [redacted] with adequate service. These actions are not consistent with Aetna’s service standards and we appreciate you notifying us of the experience. We would like to assure Ms. [redacted] that we have taken the appropriate actions to address the service issues that were experienced and will take her feedback and improve the access to our plan information available to our customers in the future.

Review: I had double health insurance coverage from late 2013 until mid 2014. Aetna was my primary insurance provider during this time, which I informed Aetna of numerous times. Nevertheless, several insurance claims were denied by Aetna by reason of not being the primary provider. I still called and straightened things out with Aetna, and was told that all such bills would be paid. I recently received an old bill from a doctor for denial of payment (because not primary coverage) for a charge that Aetna had specifically assured me they would pay. Aetna never informed me they would deny such claim after having told me they would pay it. Aetna has been completely unresponsive, and I believe they are deliberately withholding payment of a contractual obligation.Desired Settlement: Aetna needs to review my (now closed) insurance history during my time as a customer and inform me of all denied claims. Any claims that were denied by reason of "not primary provider" should be paid, as Aetna was my primary provider.

Business

Response:

Hello,

Thank you for your inquiry, 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.

Upon receipt of the complaint we immediately reached out to our Claims department to have a comprehensive review of the member’s claims completed. We were advised that there were not any claims, as of now, that were not processed as primary during the period of dual coverage. If the member has a specific claim that needs reviewed please advise of the date of service and the provider and we would be happy to review.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. [redacted]’s 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