Aetna, Inc.

Review: I was denied on a claim I made for income continuation.

I had a non work related injury involving my 2 lower left ribs in April of 2014. The injury necessitated I be out of work for a period of 6 weeks t allow for complete healing. My Aetna insurance contract for income continuation that I have had and have paid for through work for almost 8 years not once but twice (on appeal) denied my claim. They had either faxed, mailed or emailed a request for information from my doctor. I never saw what he said in the report/letter as he sent it back to them directly. my employer said that if I was going to be out of work for an extended period I needed to have my doctor complete FMLA paperwork. I picked the paperwork up at the HR office at my work and dropped it off for the doctor to complete. the paperwork has a fax number on it and requests that it be faxed to that number once completed. The doctor completed it and had it faxed back. Again. I never saw what he had written on it. The person in the office that handles FMLA paperwork at my work called me and told me he had recommended 3-6 weeks off for me on the FMLA paperwork. She advised me she was going to take me off the schedule for 6 weeks returning on May 16. I work for the state at a mental health facility. My job sometimes/oftentimes requires us putting "hands on" to escort patients or subdue them when agitated or aggressive. They wanted to make sure I was completely healed and not vulnerable to re injury. my policy states that you can file a claim for income continuation after 30 days of being off of work, I was off for 6 weeks. they said they denied me because the doctor's 3-6 week off recommendation on the FMLA paperwork was not sufficient proof of need to be off work. I think they do not want to pay because they think workman's comp should pay me. I told them and reiterated that my injury was NOT work related. Aetna and my doctor had some back and forth communications I was never privy to. If he wanted me to go back to work sooner it would have been nice if he or Aetna would have made me aware of it. The only person losing out in all of this is me because I did not get paid for my time off. I believe by not paying me they (Aetna) broke their contract with me.Desired Settlement: I would like for them to honor my claim and pay me the lost wages that I pay for them to cover if I should need them.

By the way, they only have mailing address on the paperwork I just received via certified mail on Friday. It contained my 2nd denial of my appeal.

their address is:

Aetna [redacted]

Business

Response:

Thank you for your inquiry received on December 02, 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: I had two visits at[redacted] Clinic in New Haven, CT in the fall of 2014. Between the two visits, I was in the office for no more a\than 1 hour. The medical professional that saw me was not an M.D, but rather some sort of glorified nurse.

I came about a chronic skin condition that I’d had for 12+ years. I’d seen a general practitioner over a decade ago who hadn’t told me anything particularly useful and only gave me a steroid cream that I found to be unhelpful. I specifically went to a dermatologist this go-around hoping that a specialist would care more and have more information for me. They did a biopsy, but it turned over no new, meaningful or useful information. The medical professional I saw did not tell me anything I hadn’t already figured out myself from years of research. He proscribed the same steroid cream for me that I’d told him I tried years before and hadn’t helped.

So medically, I’m back where I started. Financially, I’m down $825.52!!! And supposedly, I’m insured by Aetna. What a complete rip-off. I got nothing out of that and had no way of knowing up front the appalling amount this was going to set me back.

After receiving bills from both [redacted] and the [redacted] Medical Group, who [redacted] sent the biopsy out to for results; I looked up the cost of the procedures I was billed for on[redacted].com. The total charge at [redacted] Group was for $390 of which Aetna paid a lousy $28.55, the [redacted] price for the same procedures was only $90 total. The total charge for the [redacted] Medical Group analysis was $550 of which Aetna only wrote-off $85.93 while the [redacted] price would have been only $164 total.

That means my total “insured” out-of-pocket costs were $571.52 or 325% above the [redacted] price!!

Where is consumer protection on this? How can so many people be gouging money without doing anything useful?Desired Settlement: This so-called "insurance" company is not doing anything to meaningfully reduce my medical bills. I think it is fair for Aetna to reimburse me the difference between my out-of-pocket expenses ($825.52) and the fair market price that [redacted] pays ($254), with tha balance being $571.52.

Business

Response:

Please see our response to the complaint # [redacted] for [redacted] received on January 05, 2015.

Review: Aetna will not fully pay [redacted] Health/[redacted] for treatements for my [redacted] when their Tier 1 facilities did not provide lower extremety treatments for my type of [redacted]. If they had I would have gotten the treatments where they would have been covered at 100%. Prior to going to [redacted] I called several facilities ([redacted] near me for example. In addition, [redacted], associated with [redacted]) referred me out. Each facility that I was referred to (near my address) did not do lower extremety [redacted] treatements so I had no choice but to go to [redacted] where they did treat lower extrememties. [redacted] did not explain there would not be full coverage as well. I filed an appeal with Aetna and received a response that they would be adhering to their original decision not to pay. The three bills total: 787.11. They are broken down in three bills for: 58.19, 329.58 and 399.34. I feel Aetna should pay the full amount of the treatments for the aforementioned reasons and a simple call to the hospitals in my area would prove that they do not do lower extremities [redacted] treatments.Desired Settlement: DesiredSettlementID: Other (requires explanation)

Aetna should pay [redacted] for this claim. This should be settled between Aetna and [redacted].

Business

Response:

Thank you for your inquiry received on 04/20/2015 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.

We reached out to Aetna’s Claims department for assistance, and the claims were processed correctly according to the member’s plan benefits. The claims were paid at the in-network level, but not at the Tier 1 level. Per the member’s plan benefits, we are unable to pay services at the Tier 1 benefit level if a service is not available at a Tier 1 facility.

The member’s plan benefit is as follows:

· Hospital: Tier 1 facility, 100% after Deductible. All other facilities, 70% after Deductible.

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: All of the facilities they referred me to that were "Tier 1" facilities did not treat the physical issue that I needed addressed: lower extremeties [redacted]. In fact very recently I called Aetna and spoke to a person by the name of [redacted] who I asked to refer me to a Tier ! facility and once again each facility did not do [redacted] treatments or did not do lower extremeties. I can provide the names of all the medical places they referred me to (as I need additional treatments) and you can verify what I was told. Not one of their alleged "Tier 1" facilities addressed my needs. In fact some were baffled by my call and told me they did not do any such treatments. This was the same thing Aetna did the first time around when I ended up having to go to [redacted] hospital. Never once was I informed when asked that [redacted] had anyone that did that kind of treatment. In fact [redacted] referred me to [redacted] who in turn told me they did not do that kind of work and were not associated to [redacted]. In either case it was Aetna that dropped the ball and could not find anyone to do the treatments. In fact some of the places they referred were no longer in existance.

Review: In December 2014, I went to [redacted] care health insurance website to get some health insurance. They called me back the same day and got me started Dental, Life, and Health insurance. The dental and life insurance was no problem setting me up with autopay. They could not do it with Aetna. So I had to go into Aetna's website and pay them that way. My payment was $63.68 per month. No problem. Pay them every month. until April when I was paying for May. May payment was $411.00. I called Aetna and asked them why it went up. They stated that I needed to send in some paper work. So I sent in the proper paper work that they asked for. I kept checking online to see if they adjusted my payment and they did not. So I called them a couple more time in May, June and July. They were to check into this and call me back and no one called me back or sent me anything regaurding this issue. In the meantime the payment went up to $675.38. So in the first part of July I make a payment of $100.00 to Aetna to pay some thing. Still nothing from Aetna. Then in the first part of August I found out that Aetna autopay my credit card the $675.38. So I called Aetna back and asked them who gave them permission to autopay my credit card. They were not sure and they would have to check into it and call me back. They called me back and stated that I was set up for autopay which I was not and they sent out the information to me which they did not. I am still with Aetna and my payments now are $39.68. My bank has also tryed to help me in this problem. The last outcome with this issue is that Aetna can refund my money back and drop me from the insurance or let it go and do nothing.Desired Settlement: Refund the $675.38, adjust my bill to the correct amount with all the payments that I made to them. And stop stating that they are going to drop me. And no more auto drafts. I will pay them manual.

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 Billing department to verify why the member was being charged different premium amounts. According to the files received from the Marketplace the initial file shows an Advance Premium Tax Credit (APTC) of $384.00 and a Member Responsibility Amount (MRA) of $63.68. A change was then received effective May 12, 2015, which removed the APTC leaving the full $411.68 as the MRA. The file indicated that the member failed to provide financial information required by the Marketplace. The last file received from the Marketplace shows an APTC of $372.00 and an MRA of $39.68, received effective July 01, 2015.

Aetna does not have access to the member’s financial records and does not determine APTC eligibility; the paperwork the member mentions would have gone to the Marketplace, not Aetna. Since the member is disputing the loss of APTC she would need to contact the Marketplace to have this reviewed. Aetna has no control over the premium amount for a plan purchased through the Marketplace.

A review of billing shows the member did not pay the full MRA for May and June. The member continued to pay the $63.68 for those months which left a balance of $348.00 per month. In reviewing the paid vs. due amount Aetna billed the member correctly, but since the member did not pay May and June in full when the autopay was set up for August the full amount due of $675.36 was drafted. The member paid online every month except for the August which shows it was an autopay, set up by the member not Aetna.

Concerning the customer service the member experienced, our goal is to provide exceptional service to our customers, and immediately resolve issues when they do occur. I sincerely apologize for the frustrations and difficulties the member experienced and that we did not provide the level of service that the member should rightfully expect and deserve. These actions are not consistent with Aetna’s service standards and we appreciate you notifying us of the member’s experience. We have addressed the customer service concerns directly with the representatives who handled your calls.

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

Consumer

Response:

Review: [redacted]

I am rejecting this response because:

I did call and talk to the market place and they said that I had to go through Aetna. I called both places three times and no one called me back and let me know what was going on. And each time nobody could tell me anything. Passing the buck to each other. As far as autopay I never set up Autopay with Aetna. so why did they Autopay my account. Plus I payed them $100.00 on July 1st. What happened to that money. And when I talked to Aetna last month they stated that they could not found out anything because my Account was closed for the time in question. Aetna need to straighten this out. And yes I did turn in all of my paper work. And no I don't have Autopay with Aetna set up. They took that apond themself and set that up themself. Aetna needs to fix this, not the market place. This is Aetna's problem.

Sincerely,

Review: I have been a member of Aetna's Insurance for several years. When the Affordable Care Act began to take effect I was sent letters advising that if I wanted to continue with my current health coverage plan for the 2013 rate I would need to enroll in November, however if not I was to do nothing as I would be receiving the new rates for 2014. I have yet to receive information and have made several calls to Member Services as well as Sales with over an hour wait times and multiple transfers between departments. Today I was on the phone for over 4 hours transferred between Sales, Member Services, Billing, and Supervisors with still no resolution to their error. I was finally able to locate a number for [redacted]-Head of Florida's Corporate Office and I have left a message there in hopes that someone can finally provide an ounce of assistance. I am disgusted with the manner in which they do business and I am now going to be forced to have a gap in my coverage, which I have never had.Desired Settlement: I would like immediate resolution of the issue and for my coverage to continue 1/1/14 not 2/1/14. I still do not even know what the 2014 rates are so I feel it fair that I should be allowed to continue with my 2013 rate for January.

Business

Response:

Thank you for your inquiry received on December 31, 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 Individual Billing and Enrollment department for assistance with the member’s concerns. They advised mailing a notification letter to the member on November 8, 2013, with her options. As an exception, they processed the repurchase of the member’s 2013 plan on December 31, 2013, and her new rate is $488. The member will be able to keep this plan for 12 months. They also advised voiding the February 1, 2014 plan and they processed a $528 credit card refund. The member will receive it in 3-5 business days.

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. .

Review: I am currently medically insured through Aetna. On various occasions I have had to dispute medical bills to ensure they processed each claim correctly. However with a recent claim they failed to process, it resulted in a collections balance. I initially sought a medical procedure for my [redacted] in October of 2012. The procedure was completed by [redacted]. Some testing also had to be completed, which was sent to [redacted] Laboratories for processing. We received a bill from [redacted] requesting full payment of the test they conducted. Up to this point, previous tests were 90% covered via the medical insurance received by Aetna. Upon reviewing the bill, I quickly contacted Aetna to process the claim. They initially refused to process the claim due to a medical coding issue. Upon learning this information, I contacted [redacted] and [redacted] to change the medical code. It was changed not once, but twice in attempts to meet Aetna's coverage criteria. Still Aetna refused to cover the procedure even though it should be per my medical plan. Now the bill currently is in collection due to Aetna's refusal to cover the procedure.Desired Settlement: I would like Aetna to cover their portion of this past due balance, which includes 90% of the procedure. Thank you.

Business

Response:

Thank you for your inquiry received on March 10, 2014. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: I was told to call back in 2 days to schedule an eye doctor appt. it's been about 2.5 weeks and they STILL DON'T EVEN HAVE ME IN THE COMPUTER!!!Desired Settlement: fix the problem and pay for my first 6 eye appointments as well as 2 medical appt's.

Business

Response:

Will you please reach out to the complainant, we are unable to find Mr. [redacted] in any of our systems. Please inquire if he signed up through his employer (if so, the name of the company) or if he signed up through the[redacted] (if so, the confirmation #). Thank you for your time! [redacted] Executive Response Team

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. I found out [redacted] group the company I work at is the party at fault.Sincerely, [redacted]

Review: They said that they will pay the life insurance claim once they obtain my father's death certificateHowever, they continually send me notifications that they have not received my son's death certificateI have tried to fix this with them no less than timesThey are willfully incompetent to the point that they are failing to pay a valid life insurance claim deliberatelyThe absolute and utter run around and ineffectiveness of the customer service reps is obviously subterfuge for intentional failure to pay a life insurance claim.Desired Settlement: Pay the claim! Request the correct death certificate! Correct your records! I would also love for every single customer service rep that I spoke to--including supervisors to lose their jobsThis should be a priority
Business
Response:
Hello,

Review: This issue has been going on for months!!! I have called Aetna/[redacted] at least 4 times to resolve, I have e-mailed at least two times, I have faxed and I have sent in paperwork on the following issues to no resolve. I had a check issued from my HSA account in October of 2012. The check cleared my HSA account but the recipient ([redacted]) is saying that they did not receive the check. I informed Aetna ad [redacted] and talked with the recipient. The information on the back of the check (Bank/Date of Deposit) was provided to the recipient - they did not use the bank. I filed a fraud claim with [redacted]/Aetna over two weeks ago. I have not seen any provisional credits in my account, I have not been contacted by any customer service representatives.I need this money put back into my HSA account and for [redacted]/Aetna to do an investigation. I have bills to pay and I still owe the recipient the money. I have worked in the banking field and I know the rules and regs and [redacted] is in violation.

Product_Or_Service: HSA account

Account_Number: XXXXXXXXXXXX

Desired Settlement: I want the money put back into my HSA and an investigation to take place.

Business

Response:

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

Thank you for your inquiry received on April 16, 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 Health Savings Account (HSA) department for assistance with the member's concerns. They researched the information supplied and they need more information to resolve the issue. In order for us to research this properly, they are in need of a clear copy of a check, back and front and if can be done, any claim information, such as date of service and amount, to immediately correct any error for this member. We do apologize for the 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 other questions about this particular matter, please contact the Executive Resolution Team at [redacted].com.

Review: My complaint is that Aetna is not paying a claim I think they should. How is it that Aetna or any insurance company be able to self police claims. I pay for dental insurance and if a doctor says I need a valid procedure done, how can Aetna come back and say no! I have to pay for the procedure because they think it will heal on it's own or was not needed.My member ID is WXXXXXXXXX, procedure was performed 5/20/2013, procedure in question is a [redacted].I will also be taking this up with the company I work with

Product_Or_Service: Dental

Desired Settlement: Pay for the procedure, not place all cost on me just because they do not want to pay. No one else gets this option only insurance companies

Business

Response:

Business Response /* (1000, 5, 2013/09/03) */

Thank you for your inquiry received on August 20, 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 Dental department for assistance with the member's concerns. They advised that a pre-treatment estimate was submitted. They pended the $300.00 [redacted] procedure in the pre-treatment estimate that was issued on May 1 (before the services being performed) and requested x-rays and a narrative on the reason for the treatment. The benefit (for the other procedures submitted with the [redacted]) matched the amounts that were pre-approved. The provider and the patient both were sent a copy of the estimate.

The $300.00 fee for the[redacted] was reviewed by the Utilization Management (UM) staff and denied twice. Based on dental consultants' review of the diagnostics provided, they denied benefits on the [redacted] due to necessity as it appeared normal healing would have adequately eliminated the [redacted]. The diagnostics and information submitted thus far did show why the defect wouldn't have been able to adequately heal without the [redacted] being performed. They advised if the provider submits a narrative and/or diagnostics that shows why the defect wouldn't have normally healed without the [redacted], they can have this reviewed by their Dental Consultant to see if benefits can be 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]

Review: Company has refused to resolve an issue that they admit they made. Contacted them repeatedly and the response has always been give me 10 days. Started with the issue in January when they reset my maximum out of pocket deductible back to zero when my plan year runs through April 1st. They sent me an e-mail stated they would sent my claims back to billing for redo and adjust my accumulator. 10 days later they have sent the claims back for reprocessing but never adjusted the accumulator so it was all for naught and now they tell me it will take another 10 days to look into it further. Meanwhile they are processing claims and I am receiving billing from doctors for payment that I do not owe.Desired Settlement: All I want is them to be held accountable for the payments and for it to be processed quickly.

Business

Response:

Thank you for your inquiry received on 03/10/2014, 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.

After further review, we've adjusted the member's accumulators and reprocessed claims that went towards the out of pocket maximum in error.

Review: I was born with severe [redacted] under my finger nails and on my face and other parts of my body. I have had both [redacted] and Aetna and have always been approved for any medicine given the severity including the most expensive [redacted] and [redacted]. I recently switched to [redacted] a less expensive topical cream because I had a child and want to live a long life to care for him-[redacted] and [redacted] have been linked to cancer. [redacted] was approved by [redacted] but then I switched to Aetna to be on my wife's plan and it was denied. They are saying I don't have the right diagnosis, have some "age limit" and other cryptic reasons. The fact is that is was denied for one reason and one reason only and that is because it saves them money to deny it even if I win the appeal which takes 30 days. Aetna profits off of my pain and suffering. I am unable to work due to the [redacted] on my face and painful [redacted] under my fingers.Desired Settlement: I want the drug [redacted] approved and a formal apology for putting me through this nightmare.

Business

Response:

Thank you for your inquiry received on March 12, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you. An appeal, case number [redacted] was launched for this member and the decision was upheld and the member was notified on March 13, 2014. The member will receive a response under separate letter.

Review: Have been billed for the past weeks for a service that haven't used owe two months $200 but never used insurance.Desired Settlement: Desire that they stop billing and does not affect my credit or go to collection

Business

Response:

Thank you for your inquiry received on May 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: Aetna pharmacy shipped my prescriptions and did not have my apartment # on the package nor did they require a signature upon delivery and I did not receive the shipment. My insurance has since expired and they are refusing to reship the medications. I am now out of medication and they have not given me a resolution.Order Shipped 3 prescriptions and I was billed for the copay on 4/30/14 and tracking # showed delivered 5/2/14 [redacted] tracking# [redacted], but I never received it and post office does not have it.5/13/14 Spoke to Aetna supervisor [redacted]. She said it will reship next day [redacted], I requested a signature upon delivery. Must sign letter ion package or they will bill me again. Task id # [redacted], but I never received the redelivery shipment.5/14/14 I did not receive the redilivery but I received a phone call from the pharmacy and they said they can not reship it since my policy expired 4/30/14 because their system will not allow them to reship to expired policy holders and there is no work around. I told them this was unacceptable and I am out of medication.5/15/14 spoke to [redacted] CCR customer care rep id [redacted], escalated to pharmacy to have them re-evaluate the issue and come up with a resolution. [redacted] said I would receive a phone call within 48hrs from the pharmacy with a resolution and he is recommending it be redelivered. I did not receive a phone call.Desired Settlement: I was my medications next day aired to me immediately with a signature required.

Business

Response:

Thank you for your inquiry received on May 19, 2014. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: My husband and I have insurance through Aetna. back in Feb we went to fill our medication and it said we didnt have insurance so we paid out of pocket and then called Aetna, they said we did have insurance and to submit a claim for us to paid back for the medication. we send over the claims, and was told it took 4 weeks to process. at week 3 I called to get an update and was told a check was mailed out. a week went by and no check came so we called again, we were told they had no idea what we were talking about, no claim was ever filed. 2 days later we got a denial letter in the mail. when we called aetna, a manger told us they are not sure why it was denied but if we want we can re-sumbit. each time we call we are placed on hold for over an hour ( no joke) and transfered from agent to agent and no one can seem to help us.Desired Settlement: I want my payment for Feb back, seeing they dont want to pay any of the claims from that month anyway. we HAD insurance feb 1---- no reason why the claims should of been denied.

Business

Response:

Thank you for your inquiry received on May 8, 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: I filed a reimbursement request for out of pocket expenses on 28 Sep which hasn't been processed yet. First, the customer service staff is very ill trained, they don't understand US rules and their own company policy. After several calls to understand the process, I finally submitted out of pocket reimbursement request from my HRA account. I was told everything is fine, they can see the documents and I shd expect the claim to be processed in 7 business days. After 10 days I called to see where we are on the process, and how can I see its progress on their website or anywhere, but seems like that's not an optional at all. Anyway I was told at that time, that it could take upto 4 weeks for this process. But even after 6 weeks, I haven't received any communication and of course there is nothing on their web site.

Business

Response:

Thank you for your inquiry received on November 10, 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: I had Aetna as an insurance provider for only a few months. I went to only one doctor, two times. Aetna is refusing to pay for my doctor visits because they claim that I did not choose that doctor as my primary care physician. I told them that I did choose that doctor through their website, but for some reason, it is not showing up on their end. According to their records, I do not have a primary physician and therefor, they do not have to pay the doctor. I have filed two appeals with Aetna, but still they are refusing to pay for two measly visits. I am going to demand my money back, or file a lawsuit again Aetna. I paid for health insurance and I paid my co-pay, but they are crooks and they took my money for absolutely nothing. I got robbed. I paid for a service I did not receive and I will not go down without a fight. This is ridiculous.Desired Settlement: I would like Aetna to either pay me back the money that I paid them for health insurance that I did not receive, or I would like them to just pay the doctor. I will not pay them $250 a month for health insurance, just for myself and then have to go to the doctor to pay another $250 for just two visits. It is ridiculous and a scam.

Business

Response:

Thank you for your inquiry received on December 02, 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: In transitioning my policy from company sponsored to individual, during a company lay off, Aetna made several mistakes in their process resulting in Aetna canceling my application for the individual policy and putting me in a 60-day appeal process during which I have no policy. I had a policy during the duration of employment with my previous employer and should have had one from the time my job was eliminated through the process of the successful transfer to my own individual policy (all through Aetna). When I call for assistance, I am only told that I must take the time (hours) to describe the situation in written form, submit it to their appeals process, and wait 60-days. Aetna tells me there is no other way to handle the situation, even if I ask to speak to others. A few times when I've called, Aetna tells me a supervisor will call back. Once, I actually got a call, but it was not from a supervisor. I've explained my situation 4+ times and spent hours on the phone. No one is able to help. I've submitted the 'appeal,' but I don't really have 60-days to wait for a their result and then any pending steps they propose. I am a healthy marathon runner, so I do not anticipate issues getting a policy through another provider and going through a process from the start (as opposed to the supposedly simple transition I was doing with Aetna). It will be faster than 60-days as well.Desired Settlement: My policy should be activated no should anything happen to me. I am willing to pay premiums only for the time the company ankowledges my policy complete and active. If I am to have a policy through Aetna, I would expect paperwork only to the extent of the normal process involved in transitioning from employee sponsered to individual. If I am asked to start a brand new policy, it will be with another company. I expect a resolution in 1-2 weeks or less.

Business

Response:

Please see our response to the complaint # [redacted] for [redacted] received on February 03, 2015.

Based on our review, we have found that as of January 01, 2014, Aetna began phasing out Individual and/or Conversion plans for the state of [redacted]. We can no longer accept new applications or offer services for residents or companies of this state. Ms. [redacted] can visit [redacted].com or [redacted].gov for insurance coverage options in her area.

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: Good Afternoon, I am [redacted], Founder and CEO of [redacted], I am reaching out to you and your office for some guidance. I have been reaching out to the [redacted] Aetna Market Team since December 2014. It appears that the team has taken the position of Time Stalling in efforts not to pay the Vendor/Supplier they have been utilizing for Onsite [redacted].

This unfortunately isn't the first time this has occured. It appears that Ms. [redacted] with Aetna [redacted] Market has made it her mission to see to it that [redacted] does not recieve payment for services provided in a timely manner. This is the third time she has impeded payment for services provided.

Upon the first instance of payment delay. [redacted], of whom Ms. [redacted] reported to then asked her to put the steps down in outline manner as to have everyone on board of how the process should go for this client. Below are the steps outline by Ms. [redacted] herself this was done October 2013.

Step 1 – invoice is received by both [redacted] and myself

Step 2 – [redacted] approves the invoice (I can’t control this process)

Step 3 – I take their approval, and forward it on to our home office for processing (I forward this on within 24 hours of receiving [redacted] approval, assuming I have access to internet/emails)

Step 4 – Underwriting has to get appropriate sign-offs and approvals to authorize payment on the County’s behalf and set-up the process to recoup the money from their account (this can take 7-14 business days, depending on the amount of work on someone’s desk)

Step 5 – Once all necessary approvals are received, the invoice is forwarded on to our accounts payable department so they can release payment (it can take our accounts payable department 7-10 business days to release payment, depending on the amount of work on someone’s desk).

Step 6 – Payment is released via EFT to Dr. [redacted] account, and should arrive within 48-hours

I do proactively reach out to [redacted], on Dr. [redacted] behalf, to ensure they authorize payment. I also remind them continuously that he is a small business owner.

Once I have the necessary approvals from [redacted], I try to do the same internally.

Dr. [redacted], please let me know if you have any questions or concerns.

In September, 2014 after Ms. [redacted] was no longer the Account Executive once again payment delays resume immediately. I reached out in November of 2014 to [redacted] for assistance and finally received payment by the end of November 2014. Reference Invoice [redacted] please.

Afterwards, December 9th 2014, [redacted] Benefits Director and [redacted] VP of Human Resource and I met and they ordered 480 tests to get them through October 2015 as that would be when they would then do their big health screening of their total population. So I placed the order for [redacted] as per their request and invoiced them. I get an email from [redacted] that she has received approval from [redacted] for payment but that [redacted] would need to verify with [redacted] on how to submit payment. Then I get a call from [redacted] saying that [redacted] has instructed them that [redacted] has denied payment. That [redacted] isn't allowed to order tests in advance. Although, they have ordered it in advance since 2011 and every year thereafter; [redacted] Benefits manager at [redacted] told me that Per [redacted] she was informed by [redacted] that Aetna will not pay for tests in Advanced. Every December/January [redacted] has placed an order and been invoiced and paid. I reach out to [redacted] in January 2014 he assures he would take care of it to forward him the invoices. I do so only to hear nothing. I reach back out to [redacted] and [redacted] who says that they will see what is going on. In February 2014, I am at a meeting with [redacted] in [redacted] and I reach out to him once again to inform him about the no payment situation. He asks me again to forward him the information and that he would take care of it. He informs me then that Ms. [redacted] is no longer on this account and should not be having input on delaying payment. I tell him that is what [redacted] is saying as we are still providing services to them every month. I then receive an email from [redacted] stating that she and [redacted] are no longer over [redacted] and that I need to communicate with [redacted] and [redacted]. I reach out to them and go over the whole situation once again with them. [redacted] states she would reach out to [redacted] to get directives from her although I sent her everything I had as well. Everything I had to [redacted] and [redacted] and [redacted]. Middle of February approaches I reach out [redacted] once again and he calls me back and advices to send him everything again. I do once again. He says he would take care of it. I receive a call from [redacted], who states that [redacted] questions why the invoices are always the same. That the invoices don't make sense to her; I say to [redacted] we are on a fixed minimum for the County as per the Aetna/[redacted] agreement, he reads it and he says yes he sees it now. He then says that [redacted] was told that the county no longer wants to pay in advance. I said the county placed the order not myself I just invoiced them for what was ordered. He said, he didn't know what to offer as he doesn't usually get involved in the middle of a contract it is usually prior to a contract. I said to him that I have requested a meeting with Mr. [redacted] through [redacted] but that [redacted] assured me he would take care of it. But, I said to him someone has to be able to assist the vendor when it appears that there is an impasse or everyone keeps going in circles. If [redacted] questions an invoice without being knowledgeable of the agreement then how has she done her homework? It seems like every day this becomes a new way to stall payment and yet [redacted] is still delivering the services. I ask who I can contact within Aetna, [redacted] says he will see what he can do and try to get a meeting with everyone, but that contacting the CEO of [redacted] or of Aetna wouldn't be what he feels comfortable doing. I said, but I would think they would want to know that their vendors' are being failed and delayed payments. I am certain every Aetna Employee I have spoken with has received payment every month for working. I told him that [redacted] is on vacation he just called prior to [redacted]'s call and assured me once again that he would see to it that I receive payment and to send him the information once again. We are now March 13 midway through March and no still payment. I have yet emailed and placed calls to [redacted] with no response. We are going on 120 days of no payment. Mr. [redacted] if you could please direct me as to whom I should reach out to for help with this matter. I apologize in advance for interrupting your schedule with matters that should be dealt with I am sure by someone else but to date the runaround has been the best everyone can do at the local level. Please Advise!

March 16th I received a phone call from [redacted] from the Executive office at Aetna. She advised me that they will look into this matter immediately and that they apologize for such a delay. I told her that I am as perplexed as the next person. She said it shouldn’t take this long and that [redacted] will be reaching out as he is a Procurement specialist. As soon as we hung up I was on a conference call with [redacted] and he explained to me that there would be two additional people on the conference on the call. A [redacted] and one other person will be on the call with us. [redacted] explained that when they looked at the existing contract that the first thing was that there was no end date on the contract and that they are sending me out a new contract with an end date of 2016. I said that was fine. The original contract was created by Aetna which were [redacted] . I explained that the contract was sent to me by [redacted] and signed off by both us. That still didn’t explain why I haven’t gotten paid for services rendered. [redacted] then introduces himself and starts in on me as to why would I contact the CEO office and immediately informed me that he has been in contact with the executive office and that he will determine how things move forward. He said he is [redacted] Senior Legal Advisor and that his client has informed him they do not wish to pay for any services in advance. I informed him that his client had already signed off the approval and they themselves had told me that in person and that I have the email sent to me showing the approval. He said his client has advised him otherwise. I told them I just got off the phone with [redacted] from the executive office who advised me that they would be looking into things and would be in touch with after they look into why there has been such a delay. He said again , that he will be deciding how things move forward and that I could believe what I wanted but that the executive office had already decided for him to handle things. I said I just got off the phone with [redacted] less than a minute before getting on this call. He said he isn’t sure why she said they were going to investigate anything as the decision has already been made for him to handle things. I said I am even more confused now. Then the other person I can’t recall her name now says why [redacted] is being billed for 40 tests every month. I said its in our contract that we have a minimum of 40. She said she didn’t see that anywhere therefore she didn’t see that [redacted] County would have to pay for that. I said its in black in white. She then just hangs up. Mr. [redacted] then starts in on me again telling me what I need to do. I said to him if he is lead counsel for [redacted] then isn’t that a direct conflict of interest for him to tell me what to do. Especially since I am not asking of his opinion. I tell him my contract is with Aetna and when the contract was made it was for me to provide service for Aetna Clients not the lead counsel of [redacted]. I told them I would not be spoken in such intimidating tone by him or anyone. I would wait on [redacted] to speak further. I called [redacted] the next morning and explained to her what had occurred and she told me that she didn’t know why he would say that. She said she would seek out another counsel member to reach out to me to discuss the contract and its particular. She said she would be in touch by Friday. I received return call and then on Tuesday March 24th I receive and email from [redacted] Aetna rep for [redacted] with the list of participants for Wednesday event scheduled March 25th . I called [redacted] to advise her that I am waiting for [redacted] phone call only to get her voicemail. I went on drove down to [redacted] for the event and spoke with Executive that morning they said [redacted] was out and that they would have a manager return the phone call. I get no return call and the event is about to begin. I called and spoke with [redacted] HR Manager for [redacted] and explained to her what was going on and as to whether or not the event should be cancelled or rescheduled. She told me she would look into immediately she was under the impression I had been being paid for my services this whole time. I said NO! I have been coming down and taking care of the employees but that Aetna insists that [redacted] is advising them not to pay. While I am waiting I get a call from the executive office manager who tells me that she apologizes for such a delay and that they will look into immediately. She assured me that I will be paid but she could not speak of the details as [redacted] was out and would need to confer with her. I asked her if I should cancel the event. She said that would be up to me. [redacted] came over to the [redacted] Clinic and met with me in [redacted] office. [redacted] is the Aetna rep. [redacted] states they were not aware of me not getting paid. She stated they have not told Aetna not to pay me; but, to please send her the invoice and she would see to it that it get processed expeditiously. She apologized again. [redacted] also said he was unaware. I told them I am confused since in January , [redacted] director of Human Resources had said she had already approved the invoice. [redacted] Procurement Director told me she had already approved the invoice as well. [redacted] said just to invoice it for the quarter… January thru March event; Because [redacted] has told them that Aetna will not pay for events in advance. I send the invoice in to Ms. [redacted] and [redacted] and [redacted] G. In mid April 2015, I receive a phone call from [redacted] informing me that [redacted] is still deciding whether or not they are going to pay for the invoice. We are now near 180 days from the original invoice and to date Between Aetna and [redacted] saying that the other is telling them not to pay. The only one being held hostage is the supplier. Hostage as by definition a : a person held by one party in a conflict as a pledge pending the fulfillment of an agreement b : a person taken by force to secure the taker's demands: one that is involuntarily controlled by an outside influence. This is no different than the actions that Mr. [redacted] took in [redacted]. This is an absolute violation to myself , my business and to all minority owned companies. To whom, is one supposed to turn to for help when Corporate America decides to abuse their powers and because I reported to their own Ethics and Compliance hotline of my concerns of Title VII violation case number [redacted]. I explained to them that I am certain that this a position taken because of the color of my skin and the size of my company. Now we are going on nearly 6months. This is another display of racism in the corporate level. If this is happening to me how many other minority owned companies do you all not hear from.Desired Settlement: Payment as per the contract Agreement

Business

Response:

Thank you for your inquiry received on 05/01/15 regarding complaint #[redacted] for Dr. [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: So I was trying to get [redacted] and last Nov. my Surgeon called my Insurance company Aetna to see if I was covered, they said I was and that I had to do a 4 month prerequisite with them and then if I met the requirements I could get it. The Doctors office was given a confirmation # and the call was recorded. I did the 4 month course and spent $200 + on it and had to take off work. We also Cancelled a Family Reunion out of state because I was going to use my 2 weeks vacation on the surgery and recovery. I passed the 4 month course with flying colors and even lost 15lbs which all I had to do was not have a net gain. So I waited 6 weeks for the Insurance to process it so I could get a surgery date. Well Friday May 29th was exactly 6 weeks later and the doctors office called saying that the Insurance company was not going to approve the claim because that type of surgery was exempt. When I called Aetna and even gave them the Confirmation # and name of the person who took the call from the Doctor in Nov. the lady looked at the Transcripts and told me "Yeah he shouldn't have told your doctor that, He didn't look at your individual policy" I was crushed as I was really looking forward to this surgery to better my life, after all the hoops I jumped through and time and money I spent all because they told my doctor up front I was covered, which is the point of pre-qualifying!!!! They have to understand the Ramification of the events they set in motion by them telling my doctor in Nov. I was covered. As an Insurance company this is all they do!!! How can this guy make this mistake. Their Actions effect peoples lives...emotionally and physically. I have been overweight my whole life and at ** my doctor urged me to get this surgery. Ever since I was told by the specialist that the Insurance covered it based on that call and confirmation # in Nov. I have been excited and so looking forward to changing my life for the better and it was a long 6 months and then to abruptly have that dream crushed on Friday has been tough to deal with emotionally.Desired Settlement: I would like them to honor what they told my doctor and cover the surgery or part of it....At the minimum, I should be reimbursed the $200 for my visit to the specialist because Aetna told me I had to. I also spent $100 on Items to prepare for the surgery like protein drinks and items the specialist told me I would need.

Business

Response:

Hello,