Aetna, Inc.

Review: Failed to pay for medical services

I incurred medical debt in 2012. Aetna student health denied the claims based on a pre-existing condition. They had no right to do so as I had previously had medical coverage. Upon calling them, they told me they would send me forms in the mail to appeal the claim. I called once a month for a year and never received the forms. This caused massive damage to my credit and caused me a lot of trouble. I was finally able to get them to review the claims, but the damage to my credit had already been done.Desired Settlement: I would like aetna to contact wood all of the sources of bills that were denied as well as the credit companies to remove negative marks from my record.

Business

Response:

Thank you for your inquiry received on August 21, 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. They advised claims were under review for pre-existing and not denied. It was determined on August 13, 2013, that pre-existing did not apply as examiner received proof of uninterrupted previous coverage under member's [redacted]'s plan. All the claims pending pre-existing investigation from April 23, 2012 to February 17, 2013 were reprocessed and allowed.

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 need my drugs filled.I need Aetna to call my cobra administrator to expedite my enrollment.My cobra administrator already emailed and FAXed to Aetna all my enrollment details.The agent rejected my request.

Desired Settlement: I paid my insurance premium starting July 1st.I have not gotten insurance reinstated yet.For all the dates I do not have insurance, I want my insurance premium refunded to me.Also, I do not want them to cancel my insurance. I need it.

Business

Response:

Business Response /* (1000, 5, 2013/08/09) */

Thank you for your inquiry received on July 26, 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 issues. Based on their records, the member was terminated from the original plan effective July 1, 2013, which was loaded into the Eligibility system on July 26, 2013. The member's eligibility was updated with Aetna on July 29, 2013, for enrollment in the new plan effective date, July 1, 2013.

On July 30, 2013, the eligibility file was passed to Aetna Pharmacy Management and loaded into the system. They contacted the member's [redacted] and they said the member last had prescriptions filled on July 24, 2013, and have not tried to fill any medications that rejected.

The member's eligibility record is now showing active and the member can have their prescriptions filled. The member has incurred no lapse in coverage.

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].

Consumer Response /* (3000, 7, 2013/08/13) */

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

1) The drugs I bought are without any insurance.

2) I had to delay my [redacted] drug refill because

it is expensive and I had no insurance coverage.

I was under health risk.

I still demand refund of my premium money for the dates that I was not covered.

Business Response /* (4000, 9, 2013/08/28) */

Thank you for your inquiry received on August 14, 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 Aetna Pharmacy Management for assistance with the member's issues. They advised for any claims that the member paid out of pocket for before the eligibility being updated, the member is entitled to submit a claim for reimbursement.

The forms can be obtained from Aetna Navigator�.

The member can mail or fax the Prescription Drug Claim Form with Detailed Prescription Receipts to:

Aetna Pharmacy Management

[redacted] XXXXX

[redacted] XXXXX-XXXX

[redacted] X-XXX-XXX-XXXX

Since the member was loaded into the COBRA plan retroactive, there are no dates for which the member is not covered by the plan. The member is entitled to submit a claim for reimbursement of any charges incurred while the enrollment under COBRA was completed.

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].

Consumer Response /* (4200, 11, 2013/08/31) */

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

I did that before. It did not work.

There are discounts involved that I do not understand.

I paid full price. But then the insurance company

did not agree with the full price because they never pay full price. It was more complicated than I could comprehend. In the end, I did not get

anything back.

Therefore, I refuse to do it that way and just want my premium back to me, at least that portion.

Review: I enrolled in Aetna health insurance through the Market Place January 2015. Since enrolling in Aetna they have made claims that I have missed periodic premium payments starting in February 2015. On July 17, 2015 I had a very important appointment with the [redacted], I was called by their office on July 16, 2015 in which they informed me that my insurance had been suspended. I immediately called Aetna to find out what was going on. Aetna stated that I was behind in my premium payments, I stated to them I was not behind in payments and that I had paid every month since January 2015 and that I would not be making double payments to them. I stated to Aetna that I had all of my receipts and that I would faxed them over to them which was done , although Aetna had already suspended my insurance and cost me to miss important Doctor appointments, it was important to let them see they were not giving me the benefit of the doubt, so I had to prove that I had actually purchased these money orders and had never missed a payment. I did do a late trace on the February money order Aetna claimed they never received. I spoke to someone from [redacted] and they stated that they money order had not been cashed. The second money order missing in June 2015 was also never cashed according to Western Union. It was ridiculous going back and forth with Aetna representatives about this issue, it was very important that I kept my appointments, but because Aetna suspended my insurance I was unable to keep my appointment. I was also scheduled to have a heart catherization on July 23, 2015 and as I am typing this complaint I received a call that this procedure has also been cancelled because of Aetna suspending my insurance. I believe Aetna DID receive those money orders and shredded them, it would better for me to lose my monthly premium of $46.73 rather then Aetna lose thousand of dollars in costly testing of which I have had to have done. In February Aetna called my home and had the audacity to ask my why did I need a CAT Scan during an emergency visit to the hospital, first of all I am not the Doctor, all the information Aetna needed about me they should have gotten from The Hospitals and the Doctors, so from the beginning Aetna has been paying for costly testing none of which I ordered. I know they do not care about human life but I do ,the only thing they are concern with is obviously their own pockets. I paid my premium every month because I know how important health insurance is . Since Aetna suspended my insurance I decided, compulsively to cancel the insurance altogether, I had already missed one very important doctors appointment and one extremely important procedure do to Aetna stating that I missed payments which I did not. I Cancelled Aetna July 17, 2015 for the reasons stated above. Just as Aetna can state they never received the money orders that I sent, I state with honesty and proof that I did send every payment every month. I can not prove that Aetna shredded those money orders, but I can prove that I purchased them. One missing money order maybe, two a little suspicious. I wish I had NOT cancelled with Aetna to see how many more money orders they would claim they did not receive.Desired Settlement: I would like an apology from Aetna, I faxed over copies of receipts that I had paid them every month, they should have at least called to let me know they received the information needed. I would like $93.43 premium payments and I would also like to be compensated fairly for Aetna causing me to miss important Doctor appointments as well as a very important heart procedure.

Business

Response:

Thank you for your inquiry received on 07/21/15 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.

We reached out to Aetna’s Individual Plans and Eligibility department for assistance, and the member was originally enrolled into the system on 12/05/2014, with an effective date of 01/01/2015. An invoice was generated on 01/09/2015, and sent to the member. The member was sent another invoice on 01/24/2015, advising that their payment needed to be made or they will be cancelled. The member did not pay their initial binder payment until 01/30/2015. We do not show any payments received for February or June. Delinquency letters were mailed to the member. According to our phone records, the member did contact Aetna and requested a list of Primary Care Physicians (PCP) and specialists to be mailed to her, but nothing pertaining to the missing/delinquent payments. The member did call on 05/15/2015 about the payment and stated she would look into it. Then on 07/16/2015, the member called about the payments again and stated she would send us copies. Aetna cashes all payments received in any billing lockbox timely, and any unidentified funds would be moved to the correct account within 30 days.

We checked our system and do not show that we ever received any copies of the money orders for us to research. We also checked our system and do not show that we cancelled her coverage but her policy is delinquent. Our policy is that if a subsidized member is delinquent, their claims would be pended until all outstanding premiums are paid. Without copies of the money orders we have no way of tracking the payments.

The member stated that she called to cancel her insurance plan on 07/16/2015, but we did advise that she has to go through the Marketplace to terminate her plan. As of today, her plan is cancelled effective 07/31/2015.

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]

Consumer

Response:

Review: [redacted]

I am rejecting this response because:

Sincerely,

Consumer

Response:

I do not accept the response made by the business to resolve this complaint I did in fact send them copies of the money orders they stated they did not receive.

Review: On September 24, 2014 I received a bill from Aetna claiming that they paid for a prescription of mine in error , and they would like for me to pay them back the amount of $58.24. They claim that they paid for this prescription on 9-24-2013. My company ended our coverage with Aetna on 7-31-2013, and I was no longer an Aetna customer. After receiving documentation from my pharmacy, Aetna never paid for a refill for the drug in question on that date, or any date near there, in 2013. Furthermore, the prescription number Aetna claims they paid for was actually filled on 7-14-2014, through my current prescription provider. The amount in question, mg of drug, billing date, etc are all different. Aetna's records are wrong, and I have documentation from my pharmacy to that end. They have made an error, that does not involve me, and now they want me to pay them.Desired Settlement: I would like Aetna to drop this charge for $58.24, as this claimed error has nothing to do with me. Aetna should stop all billing requests to me, and make sure that they do not make any more "errors" on their end.

Business

Response:

Thank you for your inquiry received on 10/13/2014 regarding a prescription filled by [redacted] Pharmacy on 09/24/2013 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 and I were both scheduled for surgery on 08/05/2015. Our claim was delayed due to the need for an additional nutritionist visit that was needed. Both my wife and I completed this visit on 07/28. the paperwork was then faxed over to Aetna with control numbers [redacted] and [redacted]. we then found out, just two days before our surgery, aetna was denying the claim stating they did not recieve the paperwork needed. we have been on the phone with aetna for two days straight. we have been through over 20 people and passed around three different departments with each of them not helping. we have had representatives put us on hold and hang up on us and speak to us in a very rude matter. we were told to file an appeal, then after we did we were told we should not have because they could not expedite the process. I have reached out to the medical director of the [redacted] office [redacted], being the customer service line has done nothing and tell us he is the one to make the decision on these matters. My doctors office has been trying to get a straight answer from Aetna and that is why they have involved both my wife and I in this case. I have also filed a claim with the comm board of insurance. my wife and I have done everything as outlined in our benefit package and form 0157 to have this surgery approved.Desired Settlement: we need to be contacted by someone who can talk this through with us and give us the approval for surgery. we have done everything on our side and because aetna failed to noifiy us of the larger issue at hand.

Business

Response:

Thank you for your inquiry received on 08/06/15 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.

The member’s concerns are currently being reviewed under appeal numbers [redacted] and [redacted]. The member's will receive a resolution letter with an explanation under separate cover.

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

Sincerely,

Review: Aetna took a deposit/contribution to my account from my company's payroll deduction in January 2013 and has never applied the payment to my account.In May 2013 I asked customer service to apply the contribution to my account and no effort has been made to do so.The unapplied deposit to my account is $67.31.

Product_Or_Service: Health Savings Account

Desired Settlement: Apply the funds to my account.

Business

Response:

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

Thank you for your inquiry received on May 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 [redacted] department for assistance with the member's concerns. They advised on May 30, 2013, the fund balance on [redacted]'s Health Saving Account (HSA) was corrected to show the $67.31 contribution. The issue was caused by a system outage with their card vendor which impacted the posting of contributions. The current balance in the debit card system is $969.44, which matches the balance in the HSA system. We were advised Ms. [redacted] was called on June 4, 2013, and advised the amount of $67.31 was posted and she would see that online next to the normal contribution that was posted (2 transactions for the same amount). They assured her the balance on the debit card now matches her HSA system. We apologize for any delay and 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 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: On 3/3/13 I gave birth to my son; my fianc called aetna insurance, with whom I have a student health plan, in order to add my son to my plan. We were told that would be fine, he had to be added within 30 days, I would be emailed the form, and I should follow the instructions. I received the form, filled it out, wrote the cheque for the indicated time period on the form, and mailed it to the PO box address listed on the form. This form was returned to sender on/around 3/17/13. At this point Aetna was contacted and we were told that I should resend to the same address, when we refused we were given an address with a person to send the form and proof of return to sender, which we did. Several weeks went by and we heard nothing from Aetna and the cheque was never cashed. My fianc called repeatedly and was told he would be called back, but was not. Finally on 4/16/13 we were told that I had overpaid and that they would not accept that. They told me, I would have to pay the pro-rated amount that I was never informed of, then told me several different stories about the check I had originally sent. I was at first told it was on hold, and then later told that it was mailed back to me on 4/11/13. I have not received any check, let alone one that could have been sent on 4/11. I requested that my check be cashed, my son added to the account, and if necessary they could send a refund. They refused to do so. In the mean time, my son had a 1 month well-child visit on 4/6/13 for which they are denying any coverage, despite promises of notes on the account about their negligence. I have been informed that they may cover any charges once the account has been properly processed, however, I do not believe this will happen, given the absolute run around I have been given. I have yet to receive my original check back and currently my son has no health coverage due to their mistakes. It was also admitted that the original PO box address is closed, which they failed to ever communicate (even after the 1st send back).

Desired Settlement: I want my son to covered on my insurance plan, as originally requested and all charges to be covered, without me needing to waste more time being lied to by this company. I want my original check cashed, my account active with my son added, and no out of pocket expenses on my end due to their repeated mistakes.

Business

Response:

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

Thank you for your inquiry received on April 18, 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 Student Health (ASH) department for assistance with the member's issue. We were advised that the member spoke with a Customer Service Manager on April 23, 2013. ASH received the payment and forwarded to their enrollment group. ASH enrolled the child, advised the member that as long as funds are available once check is received, there will be no other issues. The manager will intend on having the account reviewed to make sure any denied claims are reprocessed. 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]com.

Review: I was scheduled to receive a medical procedure on 12/4/13.My doctor told me I should call Aetna and ask about my copay AND coinsurance. He told me there would be 4 claims and gave me the info. I called the Aetna number on the back of my card, on 2 separate days before my procedure. The first time I called I spoke with someone who wasn't sure, but told me it was too late to check and to call back tomorrow. The next day I called and spoke with a [redacted]l from the [redacted] office. I got disconnected from [redacted]l, and got transfered to someone who took the time to call all 4 places for me to check that I was in network and covered. I was on the phone on hold for over an hour with a lady (second call). She was helpful and told me that the only problem I may have was with the lab which was technically out of network but being used by the doctor and facility that was in network. She told me she was positive I should be 100% covered but if anything went wrong with the billing to call in and they would take care of it. I told her that I was having a hard time because of a personal family matter, and that money was tight. All the while she assured me I would be 100% covered.After that I was billed by Aetna and all 4 providers. I called and asked why and they said I had a 10% coinsurance and a 200 dollar copay. I told them they told me I didn't before hand and they said their reps weren't responsible for accurate estimate information. I was hung up on twice and ignored by email. I filed an official appeal but go no response until I went on Twitter. It took them 2 months after that to deny my first appeal.They claimed they listened to the phone calls and that I was quoted 10 percent. But they only listened to the first call, the one before I talked to the lady for a long time. When I asked for access to the transcript they told me it was "for training purposes only" which they USED AGAINST ME, so not for training purpose only. I filed a second appeal over 3 months ago and have gotten no response.Desired Settlement: At this point it has been 6 months and my second appeal has not been determined, they also are continuing to deny me access to the information they're using against me in the first appeal decision to deny.I want them to admit they incorrectly quoted me when I called before the procedure and cover the procedure as they said they would when I called. It is crazy to me that they can make a quote and then just charge whatever they want and say it wasn't a real quote.

Business

Response:

Thank you for your inquiry received on 06/05/2014 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.

The member’s concerns were reviewed under appeal number [redacted]. Based on review of the information submitted, they are upholding the previous decision regarding the member’s benefits and copayment/coinsurance responsibility. A resolution letter was mailed to the member on 05/30/2014 with an explanation of the determination under separate cover. Please allow 5-7 business days for mailing.

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. I have 3 points of reason which follow:

Review: I consulted the Aetna "Cost Estimator" prior to having an [redacted] and a follow-up [redacted]. The estimates at the Doctor's office were $188 and $500, respectively. While I expected perhaps some slight variation, since the estimator's disclaimer indicated it was an "average". Imagine my surprise when the "in network" costs were $800 and $2,200 with additional costs of $72 and $260 from the Doctor who I saw for about 2 minutes of the first visit and never saw at all on the second visit. Aetna is sticking to their "disclaimer" and the Doctor's office, [redacted] in [redacted], billed hospital rates since they are owned by [redacted]. They also billed for two other costly procedures that they had not told me about. And I specifically told them that I had to check to see what my insurance covered before I consented to the test. If a contractor or other businesses practiced this way -- understating their estimates and billing for additional work that was not authorized -- they would be sanctioned. This is devious, fraudulent and unethical practice on the part of Aetna, [redacted] Hospital and [redacted]. BUYER BEWARE! On a positive note, the CT Office of the Health Care Advocate has been very sympathetic and helpful even thought they cannot seem to get either Aetna or [redacted] to budge.Desired Settlement: I would like the charge to me to be within 10% of the cost estimator.

Business

Response:

Thank you for your rejection inquiry received on 05/30/2014 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 husband has had Aetna insurance through [redacted] department for years and one Saturday I awoke with servere pain in my [redacted] and the pain would shoot down my [redacted] and I could barely move and when I did it hurt really bad and I didn't know what was going on and and I called my husband and told him to come home and when he did he said, let me take you to the ER and I said no at first thinking it might go away but it got worse especially when I tried to walk and I went and it end up been a [redacted]. I paid my $100.00 co-pay and my husband drove me home and a few weeks later I recieved a letter from Aetne saying my visit wasn't an emergency and my claim was denied and I should have used common sense to have known that it wasn't an emergency and I owe $1,989.00 for the visit. They also said that I could have went to my regular Dr. I couldn't or didnt want to be in that much pain and not been barely functional, not knowing what's going on with my body. Monday morning wasn't on my mind,I was thinking maybe a stroke or paralyzed and since I'm not a doctor I went to the ER. On my medical record, it say semi-emergency. I thought it was an real emergency and it's ashame that I been put through and what these visit cost and you pay for insurance and they they have the nerve to make you jump through hoops to get our claim taken care of/Desired Settlement: I want Aetne to pay the claim.

Business

Response:

Thank you for your inquiry received on March 21, 2014. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you. We will gladly review the member’s concerns; however, we require some additional information. Please provide a member ID, date of service and any additional information that may assist in resolving this issue for the member. Thank you.

Consumer

Response:

Review: [redacted]

From: [redacted]

Sent: Tuesday, March 25, 2014 2:16 PM

To: [redacted]

Subject: RE: You have a New Message from Revdex.com Serving Connecticut Regarding Complaint #[redacted], date of service [redacted], DOB [redacted] branch is the ones who denied the claim and they have the medical records that says it was a semi-emergency. When I did my appeal over the phone, they put, I went to the ER because my [redacted] was hurting but that's what I said and they said it can't be changed once it been sent in.

Sincerely,

Business

Response:

Thank you for your inquiry received on March 28, 2014. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: Our daughters doctor referred her for speech therapy as she was two and barely speaking two words. The speech therapy office told us we were covered 90% and a $200 deductible. We paid our deductible and then got a bill for $300. We called our therapist office and they then spoke to Aetna who said it was billed wrongly and everything would be taken care of. We double checked with our speech therapy office to make sure before we proceeded with our daughters therapy. They and we were told that speech therapy was cover. About 2 weeks ago after going to about 8-10 session we get a call from our therapy office stating Aetna is not covering our daughters therapy because it's not covered under some specific speech therapy code requirements. Never were we told about a specific code. We were told speech therapy was cover 90% with 60 visits per year with a $200 deductible. This was the information we were given by our doctors office, the therapist office and someone from Aetna. So we asked them to call Aetna and figure this out because they figured it out last time. Here comes the creepy part. Our therapist office called and gave the reference number and name of the person who helped her and Aetna tells her there is no one by that name that has worked there. This "no one" was the third person who told us about our coverage. So who did she talk to? Who now has all of our information including my whole families SSN's? She even asked them to go through their phone recordings. Needless to say we are left with this bill and a lot of unanswered questions. We are now being told to go back and forth between our doctors office, the therapist office and Aetna. I will not be paying my bill until it is 90% coverage. I want aetna to reassure me that no one has our information? We have already consulted a lawyer about our privacy and information possibly being leaked by this "unknown worker." We are disappointed that we checked and double checked our coverage before providing our daughter what she needed and still got screwed over.Desired Settlement: I will not be paying anything. We paid our deductible and maybe owe $30-40 that I will not be paying for them giving us the run around. I want aetna to reassure me that no one has our information? We have already consulted a lawyer about our privacy and information possibly being leaked by this "unknown worker." We are disappointed that we checked and double checked our coverage before providing our daughter what she needed and still got screwed over.

Business

Response:

Please see our response to the complaint # [redacted] for [redacted] received on January 30, 2015.

Review: Needed a 90 days supply of my maintenance medication back in July 2013 because I was going out of town on some rotations required for school. I requested a vacation override from Aetna Student Health which was denied because my insurance would need to be renewed with the start of a new academic year in August. I was told to pay the cash price for the medication in July and to submit the receipts and I would be reimbursed by Aetna Student Health.I returned from my rotations and submitted my receipts and an explanation of the circumstances in October (?) 2013 as instructed. The refund was denied because there was no vacation override. I called Aetna Student Health and was told to resubmit my receipts and that the vacation override would be approved. I then resubmitted my receipts in November 2013.Since then I have called Aetna Student Health 3-4 times. I can usually only call on the weekends due to my schedule. Each time I call they tell me that that I need to get in touch with the "customer care department," and that they are closed. Each time I call they tell me somebody will get back to me within 7-10 business days. Nobody has ever called me.Desired Settlement: PLEASE refund my money. I pay my premiums on time; Aetna should pay for prescriptions on time. It is not a large amount so it probably seems insignificant to a multimillion dollar company such as Aetna, but it is very important to a struggling student like me. Thank you.

Business

Response:

Thank you for your inquiry received on February 18, 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 the Pharmacy department for assistance with the member’s concerns. They advised entering an override for the 90-day supply of the drug. The submitted Direct Member Reimbursement (DMR) from the member has been located and was sent to Aetna Claims to reprocess at the submitted amount. We apologize for the delay and inconvenience this has caused.

Review: AETNA insurance refuses to cover out of network charges in emergency situations when the hospital is in network, but the physician on duty is not.

For the second time this year, AETNA has refused to cover out of network charges in an emergency situation. On March 13th, I was 2 hours away from home at a baseball tournament. My son woke up with [redacted] coming from his ear and [redacted]. It was a Saturday and I knew no option but an ER. I asked the doctor if he was in network and he laughed, saying he did not know. He asked if I wanted to continue service and of course, I said yes. Today, April 20th, I received a $600 bill for out of network charges. I have filed a review of the charges, but based on the last denial, I'm not expecting anything to happen.Desired Settlement: I would like AETNA to charge me for in network fees due to this being an emergency situation

Business

Response:

Thank you for your inquiry received on 04/23/2015 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: My son requires special formula that is medically necessary for his survival. Aetna has currently been reimbursing us for this formula since April of 2013. I order the formula from the same company and it has always been processed as an in network expense. I sent in a claim on December 20th, 2013 and they are all of a sudden processing it as an out of network expense. I have called over 5 times on this same claim. The first several times I called, they were still reviewing it and kept telling me that it would be another 7-10 business days. We were promised on 1/13 that we would have our money in 7-10 business days and of course we do not. On 1/21, I spoke with a superviser and they had processed the claim under my name instead of my son's name. So, she corrected that and then sent it back to processing. Now, they are saying it is out of network and I would have needed preauthorization ahead of time. However, if the others were processed in network, same company, same amount, then how would I have known to fill out a preauthorization form. I have been waiting over a month for my check and I expect a refund asap in order to order more formula since my son is down to 1 can left. It is medically necessary for his survival.

Order_Number: Claim number [redacted]Desired Settlement: DesiredSettlementID: Refund

I need my reimbursement check as soon as possible.

Business

Response:

Thank you for your inquiry received on January 24, 2014. We reached out to the Plan Sponsor Liaison department for assistance with the member’s concerns. Unfortunately, the decision remains denied. They advised the provider of the formula is out-of-network. Also, the member was told by a representative on April 9, 2013, that the infant formula was not covered by the plan. The claims when submitted were processed incorrectly at the in-network benefit level based upon the member’s written request on the submission as there was no network deficiency certification on file. The claims that were processed at the preferred benefit level will remain that way and we will not pursue any overpayment nor rework the claims to the lower benefit level. However, the most recent claim for date of service December 20, 2013 and any going forward will be reimbursed at the out-of-network benefit level unless the member has a Nonparticipating Provider Request form completed and sent to Aetna Precertification for review and approval.

Review: I have had to change doctors 3 times since I started and dont want to wait 15 days to see my new doctor. I have had aetna for just over a month and I have already about had it with your company. I initially called and choose doctors over the phone with you all. Then when I get my cards, the doctors were not the ones we had chosen. Instead you had chosen different doctors that were 45 mins away from me. Would you drive 45 mins to see a doctor? Maybe if I was living in the sticks this would be acceptable but I live in a god damn city. So I choose a new doctor and even let you know that in the case they aren't available either then to choose a doctor near the same location. After that, you guys even double checked everything and called the office to confirm everything. Several weeks later, I go to make an appointment and find out that I am not accepted there. So I log into to find out what happened, as I didn't get an email or phone call or anything to let me know there was a problem. I looked up my ID card and literally say out loud, " WHAT THE [redacted] Not only did the doctor change again but she is 45 mins away. So at this point, it is open enrollment at my work and I am looking at my options. If you can't get it so that I can go see my doctor next Monday I am likely going to discontinue this policy as your service has been [redacted] bad.Desired Settlement: Ideally I would like Aetna to make it possible for me to see my newly chosen doctor before the 1rst of next month(March 1st, 2015).

Business

Response:

Please see our response to the complaint # [redacted] for [redacted] received on February 18, 2015.

Based on our review, we were informed that one of our Sr. Customer Service Professionals contacted [redacted] office on February 19, 2015, and was able to confirm that [redacted] did have an appointment scheduled for that day. We faxed an eligibility letter directly to [redacted] in the doctor’s office at [redacted], and [redacted] confirmed the letter was received prior to [redacted] appointment at 3:00 p.m.

We apologize for the delay in updating [redacted] primary care physician through Aetna Navigator. It generally takes 24-48 hours to update any requested changes. Aetna Navigator should have been updated by February 20, 2015.

We take customer complaints very seriously. If you or the member have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]

Review: My husband had been scheduled for a [redacted] surgery for 2 months via his [redacted]. Because he is a professor for a local college, we had to request a certain date at the end of the semester in order for his recovery to comply with the dates for Winter Break so he would be able to resume work on time in January. Our doctor's office had been trying to reach Aetna for about 8 days for approval of the surgery. The original surgery date was 7:30am on December 12th, 2013. Our [redacted] had finally and left a message for Aetna to return his call at 10:30am on December 11th because Aetna had not yet approved the claim nor had they returned their messages. Finally, about 4:45pm on December 11th, our doctor's office was able to reach Aetna, to be informed that the claim was denied, canceling the surgery. Due to the fact that it was after 5pm by the time we were notified with no way of possibly getting his surgery back on schedule since it was at the end of the work day, we had to rearrange all of our plans. Our doctor's office was told the doctor would need to speak with Aetna via a private line, designated only for doctors. By contacting Aetna insurance, we discovered the claim needed a peer to peer in which our doctor needed to speak with the nurse case manager to receive approval for the claim. However, when Aetna called our doctor's office, they were told Aetna would be calling our doctor. When I spoke to an Aetna representative, we were told our doctor needed to call Aetna. Yet, our doctor had attempted to called Aetna that same morning, leaving a voicemail with his personal cell phone number, and still had not received a response.After 8 days of unanswered phone calls and returned message, then finally calling the day before the surgery after 5pm, Aetna's moral and business ethics should be revised, thoroughly. My husband's surgery is not minor; it is a corrective surgery to improve his quality of life. The miscommunication and lack thereof is completely unacceptable.Desired Settlement: For Aetna to do their job efficiently. If someone is unable to return important phone calls and messages, he or she should not be hired for that particular position. Calling a doctor's office at almost 5pm the day before a scheduled surgery and denying the claim after the patient had received blood work and requested time off their job is absurd.

Business

Response:

Thank you for your inquiry received on December 16, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: After my husband was laid off we lost his company's insurance so we decided to get a quote from AETNA since we had previously been insured with this company and had a good experience. Apparently, my husband was told that in order to process the application and get the "cheapest" quote he had to relinquish our checking account information. Needless to say, their premiums had gone up since we last had them and they were not willing to insure my husband since [redacted] a few years ago so we had to continue to shop, (and found MUCH lower priced companies with dental and vision included). On November 20, 2013 I noticed a charge in my account for $225.00 from AETNA, I was in shock since we had NEVER agreed to be insured with them neither had we received ANY documentation about the insurance plan itself. I called customer service and asked why they charged me and I was not given an answer only an excuse, I asked for them to cancel the insurance plan that apparently was only for myself and my [redacted] son, and to refund the charge. I was told it would be in my account in 3 business days, though I was not happy, especially since we are struggling with my husband being unemployed-I had no choice but to be patient. On December 2, 2013 I noticed the money still had not been refunded, (and missing this money caused a few items I have direct withdrawn from this account to be rejected). I called customer service again and to my surprise was told that my request for refund had never been processed. Their customer service agent than proceeded to argue with me after my frustrations were made evident and tell me it will be another 5 business days to process the refund. My major concern is that if my request had never been processed why then had I STILL NOT RECEIVED ANYTHING from this company about the insurance policy?? This company is a scam and all about getting your money without the coverage.Desired Settlement: I would like my money refunded ASAP and an explanation from [redacted] as to why his company feels they can treat people this way and not accept responsibility for their mistakes.

Business

Response:

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

Review: Aetna is the worst. I had a medical treatment taken care of and 2 weeks prior to my treatments, I called and wanted to make sure this would be covered. The employee said yes. Since then its been a year and a half battle with these guys and every time I speak to a different representative they tell me 90 different stories of why my claim was denied and why I cant even dispute it. I have tried to escalate and make an appeal but nothing on their site works..ever.. I fax things and NOTHING makes it there forcing me to fax again once I have followed up 2 weeks later.Desired Settlement: I want my claim processed and my treatment dollars refunded.

Business

Response:

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

Review: Aetna Student Health charged me $2,099.00 for insurance when I already have insurance and a health savings account. They have refused to refund my money. I did not enroll or agree to pay for there insurance. I do not need there insurance because I already have my own. I request a full refund without further delay. Thank you.Desired Settlement: I request a full refund without further delay in the amount of $2,099.00. Thank you.

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 to have the member’s concerns reviewed. We confirmed that they reached out to the member’s university and the department was advised that the member submitted a waiver on December 31, 2015, but it was rejected as they were unable to verify – “Policy no longer active” – on this date the policy was not active as it was not effective until January 01, 2016. On January 08, 2015, the member contacted the university was able to verify the coverage and process the refund.

The university bills the student’s the insurance premium, the students do not pay Aetna directly. Per the university, they have processed the refund for the student the amount of the Spring insurance premium of $2,099.

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: I am contacting you to to request your assistance in receiving reimbursement from [redacted] (part of Aetna). After cancelling my insurance by phone/verbal notice in November 2012, without my awareness, [redacted] continued to take premiums from my checking account. When we finally noticed this, I called [redacted] and sent a detailed fax on 12/5/2013 summarizing what happened. On three different occasions, with three different [redacted] associates reviewing my case I was told that I had cancelled correctly ( by phone) , but that because [redacted] offices changed (“conversion of states to one area”) they didn’t have record from the call center and they had later changed cancellation policy to require written notices. The three associates all indicated that I should be reimbursed. The most recent reassurance occurred on 9/29/2014 when I spoke with [redacted] (spelled phonetically) in Accounts Resolution, who told me she would send my case to “escalation” and call me no later than Wednesday, October 1st regarding the issue’s status. She assured me she would work to get the process of reimbursement started as soon as possible. I never heard from her on the promised date or thereafter. On 10/15 I called and spoke to [redacted] of the Call Center. It was obvious in speaking to [redacted] that no resolution was in process. I told [redacted] I was expecting a return call from [redacted] by the end of the day (10/15/14), otherwise I would issue a formal complaint with the [redacted]. Since that call I have not received any calls from [redacted]. I have kept records of the numerous calls within a lengthy timeframe that I made to [redacted] along with associate reassurances that I would receive return calls with information on my resolution. None of this promised follow-up or reconciliation has every occurred.

For a positive resolution I am asking that I receive reimbursement for premiums paid in the amount of $2,290.40 by 11/14/2014. Given the length of time I have been in contact with [redacted] and their false repeated reassurances they will pay me in full, I believe this is a reasonable timeframe. Thank you for your attention on this matter.

Sincerely, [redacted]Desired Settlement: For a positive resolution I am asking that I receive reimbursement for premiums paid in the amount of $2,290.40 by 11/14/2014. Given the length of time I have been in contact with [redacted] and their false repeated reassurances they will pay me in full, I believe this is a reasonable timeframe.

Business

Response:

Thank you for your inquiry received on October 31, 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.