Aetna, Inc.

Review: My complaint is actually for joint communication problem between Aetna Cobra Billing Administration [redacted] and [redacted]. In March 2013 I was unfortunately let go from my job and due to prior medical conditions I was unable to obtain private health care insurance so I was forced to continue with Cobra continuation of Health Benefits. I have had to continually call Cobra and [redacted] because my FSA payments were not being applied properly resulting in me not being credited on a monthly basis for my [redacted] payments for reimbursements. If you contact both parties you will find that I have made numerous phone calls on a monthly basis to try to resolve this matter. On March 31, 2014, all claims from 2013 have be submitted for reimbursement, however [redacted] still only reflects that I am paid thru November and my last reimbursement bill is from December. I have been calling both parties since December to rectify this but as of today my December payment is still not posted to my [redacted] account even after being assured on several occasions the matter would be taken care of.

Account_Number: [redacted]Desired Settlement: DesiredSettlementID: Refund

I would like to see my final payment be applied to the [redacted] account and receive a refund for the $80.81 they owe me. I understand it is not a lot of money, but I am still not working and am no longer receiving unemployment and have no income, so every penny counts.

Business

Response:

Thank you for your inquiry received on March 13, 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 [redacted] and Plan Sponsor Liaison department for assistance with the member’s concern. They advised calling the member on March 18, 2014, and informed her the issue was resolved. The final reimbursement in the amount of $86.31 would be issued by check. The representative provided the member her direct phone number in case the check doesn’t arrive. We apologize for the inconvenience and delay.

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.

Sincerely,

Review: I am at my wits end trying to deal with Aetna. On 6/20/14 I called to cancel my individual health insurance policy, effective 7/31/14, because I was eligible for my employer's group plan beginning 8/1/14, and would no longer need Aetna. (According to the outgoing call list on my phone, I placed the call at 10:51 AM central time, and it lasted 17 minutes.) However, I received ANOTHER bill from them in July 2014 saying I owed premiums of about $300 per month for August 2014 (which cannot true, because as I just stated I called to cancel the policy effective 7/31/14), and also $300 for July 2014 (also not true, because my policy ran exactly 1 year and I already made 12 payments to them...they have NEVER straightened out this timing issue for the entire year that I was covered, despite my calling them at least FIVE times during the year I was covered. They were always one month off, because they approved me for coverage effective 7/1/13, but I opted to make the coverage 8/1/13.) So I attempted to call them AGAIN a couple weeks ago when I got this erroneous invoice, but naturally they don't answer the phone for these types of problems on the weekend (though I'm sure they answer the phones 24/7 for new business). So I instead started a string of emails through their website...the first reply accomplished nothing, and they even said they had no record of me canceling my policy (HOW IS THAT POSSIBLE?)!!! So I emailed again and got a response from a different person who said yes, my coverage began on 8/1/13, and she would make sure billing changed my end date to 7/31/14. HOWEVER, I have since received ANOTHER invoice saying I owe $300 for SEPTEMBER 2014! I am infuriated that no matter how many times I email, or how many phone calls I make this is not getting straightened out, and they continue to send me erroneous invoices, and I don't want something like this hurting my credit rating. I have tried, and tried, and tried to fix this on my own, but I can't take it any more. I've had it!!!Desired Settlement: I WANT WRITTEN CONFIRMATION FROM AETNA stating that my policy is cancelled effective 7/31/14, that I don't owe them ONE PENNY MORE, and any amounts on "outstanding invoices" are being written off.Please, please, please. Help me get this straightened out. I have wasted HOURS of my time dealing with them over the past year, and I've gotten nowhere!Thank you.

Business

Response:

Thank you for your inquiry received on 09/02/14 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 Individual Billing department for assistance, and your plan termination date has been changed to 07/31/14, per your request. You will receive a letter with the 07/31/14 termination date information in 7-10 business days.

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:

I have reviewed the response made by the business in reference to complaint ID [redacted], and want to also clarify something.

Review: My husband [redacted] worked for [redacted] & [redacted] totalling 5 years, we were insured by Aetna. In October 30, 2014, my husband lost his employment. We had regular coverage through November. In December we were able to sign up for [redacted] for $865.00/month finally. We were covered from December 1 until now. But by the time we received our insurance cards it was already December 15, 2014. We had to refill prescriptions in the early part of December totalling about $450.00. I mailed my prescription receipts in for reimbusement and was told that it was over maximum. Aetna says I will only receive $11.00!!!After 5 years w/ Aetna, they knew what our prescriptions are monthly. The prescriptions in early December 2014 was a REFILL. We were covered in December 2014. They need to reimburse the whole amount and not just $11.00. What they are doing to me is unacceptable, we paid for the coverage.This is plain wrong. Please help us.[redacted] Product_Or_Service: Health Insurance Account_Number: [redacted]Desired Settlement: DesiredSettlementID: Refund The total bill for the prescriptions in early December 2015 was about $450.00. We were covered for the month of December. I should receive every penny of it w/o copay deduction. It is their breach of contract.

Business

Response:

Please see our response to the complaint # [redacted] for [redacted] received on February 17, 2015.

Based on our review, we have reprocessed the submitted pharmacy claims from December 2014. On February 27, 2015, check # [redacted] was issued for [redacted] in the amount of $25.31 and check #[redacted] was issued for [redacted] in the amount of $174.97. The claims have been reprocessed and paid at the submitted amount and not the negotiated rate.

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: I went to an in network doctor and received a prescription that needed to be filled at a compounding pharmacy. The only nearby place did not deal with insurance directly. They provided me a form to mail to my insurance company, Aetna, for reimbursement. This was October 18th, 2013. I have been fighting with Aetna since then to get them to cover this under my prescription plan. The first time I submitted the form it was rejected for missing information yet everything was correct on the form and what they claim was missing was right there. I ended up refiling and this time it went through. The prescription was $79.28 and they only claimed $4.80 was allowed. When I called to ask questions, the representatives don't know anything and have told me several times it has to be sent to the claims department and someone will call me back. No one has called me back for months and I call back several times a month trying to get this resolved.Desired Settlement: I want someone at Aetna to speak to who can help me with this claim, explain why it was not covered in accordance with my plan and figure out what I need to do to get it resolved. I just want someone to own this issue start to finish and help me.

Business

Response:

Thank you for your inquiry received on March 17, 2014. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to Aetna Pharmacy Management for assistance with the member’s concerns. Based on our review, Mr. [redacted]’s claim for the [redacted] medication was submitted as a 60 day supply which exceeds the member’s retail plan benefit maximum of a 30 day supply. Additionally, the only covered ingredient is the [redacted] which is a Tier 3 drug under the member’s plan benefit. If any exception would be made to allow the 60 day supply claim to process under the plan benefits Aetna would impose a 2X Non-Preferred retail copay of $120 on the claim. Since the 2X retail copay of $120 is greater than the amount the member paid out of pocket at the pharmacy ($79.28) there would be no refund issued to the member off the claim.

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:

Review: [redacted]

I am rejecting this response because Aetna did not address my original concerns. I want someone to call me to discuss the details of my claim and someone to listen to my specific situation. They also did not address the question of the "compounding fee". I had to deal with a pharmacy that does not accept Aetna insurance and they told me "just send this form to your insurance for reimbursement". Also, the doctor has my insurance information yet still wrote a prescription for 60 days when it was unnecessary. I don't use my prescription plan often so if I had known, I would have told him to change it to 30 days. The primary problem here is that I had to pay out of pocket for the prescription and fight with Aetna after the fact not knowing what is covered/not covered under my prescription plan.

Review: Paying COBRA at -$800 per month. Insurance cut off since July 1, 2013, although check for coverage was cashed by AETNA. Doctor bills coming in for non coverage from July, cannot schedule a procedure, cannot pick up [redacted] prescription. September payment automatically scheduled for September 1 and on going for the first of every month. COBRA was to start July 1. AETNA late with paperwork, but quick to take payments. Had to call for paperwork and coupon book that has not arrived. Insurance is fraudulent.

Product_Or_Service: COBRA

Account_Number: [redacted], Dental, PrescDesired Settlement: DesiredSettlementID: Other (requires explanation)

Want insurance coverage from July 1, 2013 for outstanding medical bills. Want insurance immediately instated for procedure and [redacted]. Really, should I die of an [redacted] attack because AETNA cannot process paperwork?

Business

Response:

Thank you for your inquiry received on September 26, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: Aetna canceled my health insurance but never notified me of the cancellation. I received and paid the bill for the premium each month. After multiple calls and being placed on hold for over 2 hours, I was finally told they sent the cancellation to an old address. I had already given them my new address. Why do I get the bill sent to the correct address but not the cancellation? I forwarded my mail and had no problems receiving everything else (I don't think they ever sent it anywhere). According to Aetna, since I did not respond saying I wanted to keep the insurance, they cancelled it but took payment for January 2014 even though my insurance was cancelled as of December 31, 2013. My plan does not come up for renewal until July 2014 so they can't just cancel early. My plan met the minimum ObamaCare requirements. This is a scam to illegally get rid of me. I want my insurance re-instated. ObamaCare is too expensive (4 times what I am paying now). Re-instatement is my only acceptable solution with Aetna for their wrongdoing.Desired Settlement: I want the same insurance plan, same costs ($221 a month), same everything.

Business

Response:

Thank you for your inquiry received on January 3, 2014. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: Aetna plan documenation states $35 copay for service coverage, and no charge for preventive care.Coverage provided resulted in over $500 in medical bills, and was not covered under $35 copay cost.Appeal response was "you're responsible for paying" rather than explaining why the covered services weren't covered according to plan documentation.Desired Settlement: Looking for reconsideration of appeal, case # [redacted].Aetna plan documentation states that Prenatal and postnatal care falls under $35 copay in-network. No charge for preventive prenatal care. Coinsurance applies outside of office setting.We received bills for every visit, and we were not just subjected to the $35 copay, but a large portion of each bill.Appeal was denied with vague answer of "you're responsible for paying".

Business

Response:

Thank you for your inquiry received on January 17, 2014 regarding the copayments applied for the claims for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: After being promoted at [redacted], my new union forced me to switch to Aetna coverage as of 1-1-15. I have taken generic [redacted] since I was diagnosed at the [redacted] in 2007.

1-8-15 I picked up my prescription from my doctor in person, delivered prescription in person to [redacted].

1-9-15 Pharmacy reports Aetna demands prior authorization. Medication has run out.

1-12 [redacted] submits 2 prior authorization forms via fax.

1-13 [redacted] submits 2 additional prior authorization forms via website.

1-14 [redacted] submits another 2 additional prior authorization forms via email.

1-15 Aetna denies prior authorization, states appeal process takes 31 days.

1-16 The drug is taken in conjunction with an antidepressant, but with sudden withdrawal I am now experiencing suicidal thoughts. Aetna refuses to accelerate the process, even though a licensed doctor appealed denial of coverage.Desired Settlement: In life-threatening cases, the appeal process must be accelerated. The answer is not to have insurance members needlessly clogging up emergency rooms simply because they cannot cover the cost themselves in the interim. (In my case, $350.00) Furthermore, transparency must be instituted. The group that makes these guidelines does not have a web site, email address, contact name or even a phone number: just a PO Box # and fax #. Finally, customer service must be improved. I've spoken with everyone at this company that I could and every single one treated in contempt as if I was a criminal/addict. If a member asks for the guidelines specifics, don't say "Ask your doctor, I'm not allowed to tell you the reason why you were denied." The nurse line mocked me, stating "Why not get a second opinion?" and laughed. In short, dragging this process out with no flexibility is not an action a company should be allowed to do while serving Alaskan customers.

Business

Response:

Please see our response to the complaint # [redacted] for [redacted] received on January 20, 2015.

Review: I purchased a group health plan through the Aetna marketplace for [redacted] for my small business that includes my family personally and our employees. I submitted everything to them to get the policy in force at the end of December 2014 for a January 15 effective date. It still wasn't issued as of 1/15, but our account was drafted for it. I had to call multiple times to push the issue so we could get our ID cards because we needed to cancel our current plans, and we weren't going to without proof of coverage. Our ID cards weren't available until 1/27, and our prior carriers would not back date our cancellations to the 1/15 date, so myself and my employees ended up paying for duplicate coverage as well. Our ID cards ended up being issued incorrectly with the wrong business name and coverage on them, and they had to re-send new ones. These also ended up being issued incorrectly, but we found out after needing to get medications filled . The plan we chose is supposed to have the deductible waived on generic medications, but when we went to get medications, we were told by the pharmacy that that was not the case, and one of our employees has necessary medications that they cannot go without. He was told he would have to pay $500 for his generic meds, I was told the same for a different medication for my son. I called our rep to find out what was going on because Aetna's pharmacy line showed all meds applied to our deductible, but our rep could see on her end that the deductible is to be waived. I reported this issue to aetna last monday, february 16, and as of today, february , 23 I am told they are working on it. Our employee is completely out of their necessary medications, and Aetna admitted it was an error and it's being worked on, but we are still unable to use plan as needed that was issued on 1/15. We want to keep the plan, but it shouldn't take over a week to fix something that was their mistake. It has been one issue after another with Aenta, and we have all canceled our prior health insurance plans. We just need everything fixed in a timely manner, and it's not being done efficiently.Desired Settlement: Correct health insurance policy that we applied for.

Business

Response:

Please see our response to the complaint # [redacted] for [redacted] received on February 24, 2015.

Based on our review, we found that the group [redacted] was approved by underwriting on January 8, 2015, for a January 15, 2015, effective date. They were made aware that they would not have members enrolled with ID cards in hand by January 15, 2015. The Aetna Market Place for [redacted] call center agent advised the customer that their employees can shop and enroll from January 15, 2015 until January 30, 2015. The call center agent advised the customer that members must have 15 days to enroll.

The ID card issue was brought to our attention on January 30, 2013, by the customer and on February 2, 2015, we confirmed that this was corrected on January 29, 2015. The pharmacy issue was brought to our attention on February 18, 2015, and it was resolved on February 24, 2015. The Aetna Marketplace for [redacted] call center team was in contact with the customer throughout the process to advise of the status and to confirm the issues were resolved. However, we do apologize for any inconvenience these issues may have caused.

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]

Consumer

Response:

Review:[redacted]

I am rejecting this response because:

Review: In 2013 I received a series of allergy shots (immunizations) through the office of Dr. [redacted], located in [redacted]. The protocol was - according to the Dr. office - discussed and approved in advance of the services rendered with Aetna.

The Dr. office received the reimbursement for these services from Aetna, however, in the summer of 2014, Aetna informed the office that it was withholding $291.70 as "too many shots had been given over the course of 12 months". The Dr. office is now attempting to collect these funds from me.

I had filed an appeal to Aetna as they had previously approved the treatment plan (according to the Dr. office information). Yesterday, I received a denial from Aetna.Desired Settlement: I ask that Aetna pay the Dr. office the amount of $291.79 that they had previously committed to.

Business

Response:

Hello,

Review: I was admitted into the hospital on 1/2/15 I called Aetna and asked if the hospital was in network because my doctor had treated me with 3 courses of antibiotics for possible pneumonia. Nothing helped I went in her office on 1/2/15, and she said she was admitting me. I called Aetna in front of the staff in the office and was told it was network. I was admitted in and given antibiotics through IV because medication by mouth was not doing anything. I received a bill for 88,000+ from the hospital and the insurance company denied my claim because they said I could have been treated adequately outside the hospital. If I could have the doctor wouldn't have admitted me. I spoke to the hospital rep today who stated Aetna was provided all the information they needed and they are still denying my claim. So how can you deny a claim when medications were not helping, and not to mention I have high blood pressure that they could not control.Desired Settlement: I believe my bill should be paid. Aetna is saying they don't have the medical records which is not true they were sent by the hospital.

Business

Response:

Hello,

Review: I had been working with our network rep, Vanessa K[redacted], to update our group NPI/TIN. She did this, and our new contract with Aetna was effective April 1, 2015. She was supposed to be helping me update this information with Aetna Better Health. When I reached out to her to follow-up, I found she was no longer at Aetna. I received an email back from Chris G[redacted] directing me to Jennifer W[redacted]. I sent Jennifer all requested information on June 5, 2015. Since that time, Jennifer has not responded to any emails I have sent following up on this request or to determine a time frame for this to be effective.

In addition, Vanessa did not add one of our associates to the new contract. I was put in contact with Heather P[redacted], who had our associate sign the electronic agreement on June 17. Since then, Heather has been unresponsive to my emails about whether our associate was ever linked with our contract. I spoke with credentialing on July 29 and they informed me that our associate has NOT been linked with our contract. This should have been done in MARCH, and she should be effective with our contract on April 1, 2015.

The only phone number to call about this is [redacted]. The only way to get a representative on the line when calling this number is to enter a member ID number and go through all the benefit details. I went through this process on July 29 and I requested to speak with a supervisor. The rep told me there were no supervisors available, and that someone would call me back within 24 hours. I never received a phone call.

This is completely unacceptable that a) the changes to our contract were not made when they were supposed to be; b) there is no way to contact a representative; and c) that Aetna reps do not return emails or calls. Vanessa K[redacted] apparently no longer works there. Christine K[redacted] phone number is no longer working. Christine G[redacted]'s (our credentialing rep) email is no longer working. Heather P[redacted] and Jennifer W[redacted] are not returning emails. I have no contact person at Aetna and the best suggestion the rep gave me was to fax a letter to Provider Credentialing, which I did on 8/1/2015.Desired Settlement: I need a representative from Aetna to contact me immediately. I have called and emailed several representatives many times and never received return communication. I need immediate assistance with figuring out who a contact person is for our group. I also need to ensure that our associate is correctly added to our contract. Finally, I need our new information to be updated with Aetna Better Health.

Business

Response:

Hello,

Review: I have been calling since January 2015 speaking to several representatives regarding a bill I received from a health care provider for a visit on 7/29/2014 (my annual check up). During my visit, they did routine blood work which should have been covered by my health insurance plan with Aetna. However, Aetna keeps rejecting the bill and I am getting billed to this day from the provider.

In April 2015 I received a voicemail from [redacted] at Aetna stating the outstanding balance for laboratory work was being processed and payments were being sent to the providers. I saved this voicemail on my cellphone. On June 16, 2015 the provider called to say that they never received the payment from Aetna for the lab work. Therefore, there is still a balance. I am tired of calling and speaking to different customer service representatives and getting no where. This was not out of the ordinary medical treatment. This bill needs to be paid immediately by Aetna.Desired Settlement: Aetna needs to make payment to DOCS immediately for the blood work done during my annual check up.

Business

Response:

Hello,

Review: Aetna has done a poor job of keeping data to include what out of pocket costs, and also contract stipulation of what routine vs. medical procedures are included. I recently had a procedure which was included in my policy to be covered and received a bill re: out of pocket expense due to it being a non-routine. No procedure would have been done without a doctors approval.Desired Settlement: Would like to have my procedure covered.

Business

Response:

Hello,

Review: I would like it on record. I have been informed on multiple occassions from Aetna - stating from a form letter sent to my address TWICE - (As of Febuary 10, 2014, Our records show that you have not complet the Health screening portion of the 204 wellness activiitie to kee th4 $500 credit toward your annual Bank of America Heal plan premium.) It as duly noted in the several phone calls I have made today speaking with Shanya, and Peter whom once again stated they have NOT received any of my wife's information. Please not [redacted] has completed both portions per quo. And essentially faxed in the information of which I was again informed by both of these Customer advocates they show NO RECORD of FAX or results. Which Sonora quest labs performed December 2013. Also I was given false information from Peter stating to call Maxim labs. Which of course had no record and Molly from Maxim stated we would need to contact Bank of America Human resources department to receive the information from Sonora labs.Furthermore Aetna representative Lynn informed me they have nothing to do with Sonora labs processing the information. In closing I have not received any confirmation of the completion of my wifes activity, nor received any calls from a supervisor to this point to explain why I was advised to have my wife FAX in documentation the activities have been completed.Desired Settlement: I would like a formal explanation from an executive to explain why this information being providing is FALSE. Also explain why you have no updated fax capabilities in the year 2014. Why you contracted out a service stating the wellness activities will be provided without any information needed from me personally other than a MEMBER ID #. And why is the purpose of the activity when you put everyone in the same health box. When everyone's bodies are TOTALLY different.

Business

Response:

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

Review: Aetna failed to respond to a claim appeal I originally submitted in August of 2014 after repeated follow-up on my part.

This complaint is in regard to Aetna's failure to respond to a claim appeal I originally filed in August of 2014. Below I've included all of my details, the timeline of my interactions with Aetna and the text of my most recent appeal letter. I have supporting documentation available for my case, which I will email to Revdex.com.

Member/patient name: [redacted]

Aetna ID [redacted]

Group #[redacted]

Group name[redacted]:

August 21, 2014 - I sent my original appeal to Aetna.

September 23, 2014 - I followed up by phone with Aetna's Customer Service department to find out the status of my appeal as 30 days had lapsed since its submission. A customer service representative [redacted]) said there was no record of my appeal and advised me to submit to a different address (Aetna's Middle Market CRT) for expedited processing of my appeal. I submitted my appeal for the second time.

Mid-October, 2014 - I received a postcard from Aetna that they had received my claim and were processing it.

December 24, 2014 - I sent my third written follow-up to Aetna's Appeals Resolution Team as more than 60 days had lapsed since my second attempt at securing resolution to my appeal.

My Most Recent Appeal Letter:

Appeals Resolution Team [redacted] December 23, 2014

To Aetna Appeals Resolution Team:

This is the third time that I have contacted Aetna's Appeals Resolution Team to appeal claims that were inadequately reviewed and processed by your organization. As of December 23, you have not responded to my appeal, which you originally lost when I submitted it on August 21. I again submitted my appeal to what I was told was your expedited appeals processing group (i.e. Middle Market CRT) on September 23. I was hopeful this time around that my appeal was being processed when I received a postcard from your team in mid-October that you had received my appeal. As it is now almost January 2015, and well past the 60 days Aetna is supposed to deliver a decision on first round appeals, I take it you have again lost or otherwise opted to ignore my appeal.

At this time, given your complete disregard for my appeal I am filing grievances with the following organizations:

(1) [redacted] I have attached all of the documentation previously included in my original appeal and my follow-up. You can reach me at +[redacted] if you would like to discuss my claims.

Thank you,

Cc: [redacted] from Aetna regarding my claim, received in mid-October

Letter to Aetna Appeal Resolution Team, dated August 21, 2014

Invoice dated April 9, 2014 for appointments in February 2014 from [redacted] Invoice dated April 9, 2014 for appointments in March 2014 from [redacted] Invoice dated May 1, 2014 from [redacted] Voltage SecureMail message dated August 14, 2014 from Aetna

Aetna statement dated June 17, 2014 (Claims [redacted])

Aetna statement dated July 1, 2014 (Claims [redacted])

Aetna statement dated July 11, 2014 (Claims [redacted])Desired Settlement: I want Aetna to apply at least 70% of my out-of-pocket expenses for the claims in question against my out-of-network deductible. But overall, I want they to respond and actually review my claim rather than "losing" or ignoring it, as they have done to-date.

Business

Response:

Thank you for your inquiry received on 02/06/2015 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: Aetna not updating correct medical plan information about my plan because of which my medical claims are not processed correctly. I enrolled for low deductible plan and paid premiums accordingly but in their system they have updated it as high deductible plan and processed claim accordingly which is wrongDesired Settlement: Fix my health plan in the system and process the claim accordingly

Business

Response:

Thank you for your inquiry received on 06/30/2015 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: Coming from a company that changes health insurance carrier every other year, I'm starting to become more and more familiar with claims and how they are processed by certain carriers. AETNA is by far the worst. From the EOB's that make absolutley zero sense, to the customer service that really has no buiness being in an industry that deals with someone's health and financial well being. I've spoken with a handful of representatives and they should all be processing orders at the drive through, not health insurance claims. The latest version being the flat out rude representative that simply tells me that the dispute for a claim (anethesiologist the IN NETWORK hospital sends into our hostipal room while my wife is contracting is OUT OF NETWORK) will not be reprocessed and the provider is demanding the entire amount. Ironically that determination comes 2 business days after our company has dropped Aetna as the health insurance carrier, but the dialouge about this dispute was going for 60+ days. It had only been disputed for 60 days because we hadn't recieved a bill for that particular service until April 2013.... and my daughter was delivered [redacted]The root stem of all this nonsense is the fact that I was told plan changes could be made up to 30 days after the "life changing event". That being said, when our daughter was delivered and all everybody was healthy, I did what any smart person would do, and lowered our out of pocket expense by changing insurance plans from a PPO plan (ind deduct of $1500) to the HSA 2500 plan (ind deduct of $2500). Even though we didn't change the plan until 9/17 ( less than 30 days from the 8/21 event) the plan change went retroactive to the delivery date and all the subsequent claims were processed against the new plan. The fact that it was going to go retro was never explained, and the fact that plans were calander year was never explained either. Big difference and I would have chosen plans differently.Desired Settlement: I would like Aetna to take reponsibility for the $1050 anethesiologist bill for a couple reasons. First, I would have met deductibles and out of pocket max if the plan did not go retro active. I wouldn't have been paying the higher premium for the PPO if I would have known all the delivery related claims would go against the new plan and its deductibles. Second, I've had to deal with all these claims and disputes for practically a year now, and this is in no way/shape/form any of my doing.

Business

Response:

Thank you for your inquiry received on August 8, 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 Small Group Business and Legal department for assistance with the member's concerns. Based on the information provided, they overturned the decision and they will need to change the effective date of the plan change for the member/family to September 17, 2012. Since the group terminated their coverage effective August 1, 2013, the Eligibility department will work with the Claims department to adjust the claims. Please allow some time to make the necessary changes and once done they will inform 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.

Business

Response:

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.

The claims department has reprocessed the anesthesia bill under claim number [redacted]. The expected issue date on this claim is September 6, 2013. We apologize for the 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.

Consumer

Response:

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

I will not be able to accept the offer until I actually have a resolution. Reprocessing claims only means I'll need to do all the research into making sure my claims were processed corretly and applied to the deductibles correctly. The nightmare continues.....

Business

Response:

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

Review: I had to have surgery and was ordered by my doctor to be off for two weeks. I also am a diabetic with uncontrolled sugar levels and have a history of scar tissue or endometerosis. Aetna has denied my claim and refuses to pay me for short term disability. I was told by them since I sit at my job there was no reason why I could not have surgery on friday and be back to work on Monday. I was also told that my job did not require lifting. Even though I was on pain pills (narcotic). I told them I could not even drive due to the prescription. Then I was told I did not have to drive my self to work. I am considering suing them in small claims court. My lawyer has advised what if I went back to work that Monday and then had complications, then I am sure Aetna would have said well she did not follow her doctors orders.LDesired Settlement: DesiredSettlementID: Other (requires explanation)

I would like to be PD for my week of short term disability that they owe me. After all, I do pay my for my health insurance every month $400.00. If they are doing this then why even have health insurance?

Business

Response:

Thank you for your inquiry received on 06/27/2014 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: We had health insurance coverage through Aetna Life Insurance Company for our business for several years in which we paid on time and regularly. Our policy was from February 15 - March 15, 2014. We decided to terminate our insurance coverage for the month of March, 2014 since we purchased other insurance. We sent a letter to terminate to Aetna effective February 28, 2014 and we paid Aetna 1/2 of the amount owed to cover our coverage of our insurance up to March 1st. They are now claiming that we owe them for the 2nd half of (March 1- March 14) even thought we terminated and paid for what coverage we did have. Now they are sending me collection notices for 1/2 the amount for coverage I did not have. We have spoken to them and sent all of our information explaining the situation but now they are sending this to an attorney claiming that we still owe the money for 1/2 month.Desired Settlement: We expect not to pay for coverage we did not have and terminated in the proper fashion and paid up to the amount that was owed.

Business

Response:

Thank you for your inquiry received on 09/12/2014 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.