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Aetna
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Los Angeles Aetna Health Insurance Denial Lawyer

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Being Denied a Service or Treatment Can be Frightening— Scott Glovsky Will Fight for You and Your Future

If you have been denied a health service or treatment by your health insurance company, you may feel helpless, unsure of what to do. After all, your doctor believes the service or treatment is necessary for your health. You can end up feeling powerless and abandoned by the insurance company that promised to take care of you. Scott Glovsky understands these feelings and will step in to help you during this difficult time. Scott has made it his mission in life to fight for justice with all his heart and soul, staying fully committed to his clients. Scott is passionate about fighting for those who cannot fight for themselves. Trying cases allows Scott to tell his clients’ stories and get justice for them. Attorney Scott Glovsky is relentlessly tough with insurance companies, working hard to ensure a better future for his clients.

Facing an Aetna Denial? Contact Us Now

About Aetna

Aetna is one of the nation’s leading diversified healthcare benefits companies. Aetna is a CVS Health company, with more than 40 million customers relying on the company for healthcare, in California, Aetna is the sixth in the number of members. Aetna plans and services include medical, pharmacy, and dental plans, Medicare plans, Medicaid services, behavioral health programs, and medical management.  The Aetna healthcare network stretches not only across the nation, but also across much of the globe, with roughly 1.2 million healthcare professionals, more than 700,000 primary care doctors and specialists, and more than 5,700 hospitals. Aetna offers a wide range of insurance and employee benefits products which include tools and information to help people make better-informed decisions regarding their healthcare.

Like other insurers, CVS Health has diversified into other healthcare areas. It owns the health insurance company Aetna, the Pharmacy Benefit Manager CVS Caremark, CVS retail pharmacies, MinuteClinic medical clinics that operate in some CVS pharmacies, some primary care providers including Virtual Primary Care that offers 24/7 on-demand primary care and mental health services, Oak Street Health with clinics that focus on older adults, and more. In August 2023, CVS announced it launched its Cordavis subsidiary that will commercialize and sometimes even co-produce biosimilar pharmaceutical medications.

Aetna was founded in 1853 in Hartford, CT, playing a key role in building a simpler, more integrated healthcare system.  Aetna serves employer groups, individuals, government-sponsored plans, healthcare providers, labor groups, health plans, college students and part-time and hourly workers. Aetna was the first national full-service health insurer to offer a consumer-directed health plan.

Aetna Violations

On January 24, 2022, California’s Department of Managed Healthcare (DMHC) fined Aetna $500,000 for violations of the Knox-Keene Act and accompanying rules and regulations. Specifically, Aetna and its affiliates had been improperly handling emergency room claims since 2017. California law stipulates that health plans consider a policyholder’s subjective belief that they experienced a medical emergency when they evaluate whether a visit was medically necessary. In the settlement, in addition to the fine, Aetna paid back $306,800 in claims and agreed to abide by California law when evaluating future ER claims. In 2022, the DMHC overturned 37.5% of medically necessary Independent Medical Reviews (IMR) and, after the IMRs were filed, Aetna reversed its denials in 12.5% of the cases.

In 2021, the DMHC fined Aetna $85,000 for failure to correct nine deficiencies. Among others, the deficiencies included several failures with its grievance system. They also included a failure to make timely utilization management decisions and to communicate these decisions in writing. In 2021, the DMHC overturned 53.8% of medical necessity denial appeals and, once the IMRs were filed, Aetna changed 38.5% of its denials into approvals. In other words, of those who appealed medical necessity denials in 2021, 92.3% of them ultimately received the care they needed.

The Cost of Aetna’s Denial of Claims

Health insurance policies are contracts, and as such health insurance companies such as Aetna have a duty to engage in good faith and fair dealing. This mandates that neither Aetna nor any individual holding the policy would do anything to injure the other’s rights to receive the benefits of the agreement.

For the insurance company, this means they get paid. For the policyholders, it means they receive the care guaranteed under their insurance policy. However, all too often an insurance company denies a claim for a seemingly mundane reason, leaving policyholders with thousands of dollars of medical debt.

If Aetna denied your health insurance claim, you have the right to appeal its decision with the help of a health insurance denial attorney – like Scott Glovsky. A Los Angeles Aetna health insurance denial lawyer can help you navigate the complexities of insurance law and appeals and work to recover compensation for your losses or help secure coverage for a procedure. You can learn about fighting a denial by downloading our eBook on this topic.

Health care costs have climbed dramatically over the last several decades. According to statistics released by the Henry J. Kaiser Family Foundation, the national average daily cost for an individual to stay in a hospital is slightly over $2,000. The average cost for an individual to stay a single day in the hospital in California was closer to $3,000 in a state or local government hospital and $3,752 at a non-profit hospital. These statistics underline the importance of having an insurance policy.

What are the “Typical” Coverage Denials from Health Insurance Providers Like Aetna?

Insurance companies may give all sorts of reasons for a healthcare claim denial. While some of these reasons could be legitimate, many others are not, having more to do with the company’s financial bottom line than anything else. If you are unsure why your insurance claim was denied, you should have received an Explanation of Benefits (“EOB”) which will tell you the reason for the denial. The most common reasons for denials from health insurance providers like Aetna include:

  • Your doctor provided insufficient evidence of medical necessity
  • You failed to use an in-network provider
  • You failed to obtain prior authorization or pre-certification for your service or treatment
  • Your procedure or treatment is considered non-essential or elective by the insurance company
  • There were coding errors for your diagnosis or procedure
  • There was an omission of the diagnosis or procedure
  • The insurance information was incomplete
  • The insurance information was inaccurate
  • Your filing time limit has passed
  • You have not yet paid your deductible
  • You failed to pay your co-pay
  • Your application was incorrect or incomplete

Whatever reason your insurance company gives you for denying coverage for a treatment or procedure, they must provide a written explanation that includes information for an appeal of the denial. When the process set forth by the state of California for appealing a denial fails, you have other options for appealing the denial of your claim.

A health insurer denial lawyer like Scott Glovsky can help you appeal your denial of coverage. Whether your denial involves an outright denial of treatment or a refusal to reimburse already-received treatment, having a highly experienced health insurance denial attorney in your corner can help ensure enforcement of insurance policies.

How to Appeal an Aetna Denial of Coverage

If Aetna denies your legitimate claim, you can print a Member Complaint and Appeal Form and appeal the decision on your own, or you can hire an experienced attorney who files these appeals on a daily basis for people just like you. You have 180 days from the time you receive notice that your claim has been denied in which to file an appeal. If your plan provides for only one appeal, and if/or Aetna had to approve your claim before you received care, the company will make a decision within 30 days of receiving your appeal. For all other claims, Aetna will make a decision on your claim within 60 days.

If your claim provides for two appeals, and Aetna had to approve your claim prior to receiving the service, the company will make a decision on your appeal within 15 days of receipt of the appeal. For all other claims, Aetna will make a decision on your appeal within 30 days. For two appeal plans, if you do not agree with the decision made by Aetna, you can ask for a second review within 60 days of the date you receive the first appeal decision.

If your situation is urgent—that is, if you doctor feels a delay will put your health, your life, or your recovery at serious risk or cause you pain, then you are entitled to file an expedited appeal. If your plan has one level of appeal, Aetna will give you its decision no later than 72 hours after receiving your request for review. If your plan has two levels of appeal, Aetna will provide a decision no later than 36 hours after receiving your request for review.

If your claim is still denied after your appeal, you may be entitled to have an independent party review your claim denial. This is known as an external review. The Affordable Care Act created new rules for health plans; plans that are subject to these rules must include an external review process.

FAQs Regarding Aetna Coverage Denials

If you have been denied healthcare coverage, you may have many questions, including:

What Are My Rights in California When Aetna Denies My Claim?

Receiving a denial of a health insurance claim can make you feel as though you have no rights because the process is complex, usually placing the burden of proof on the patient. The feelings of powerlessness come from knowing that Aetna has vast resources, legal teams, and medical reviewers to make decisions based on internal policies that can be difficult for the average person to understand. The language used in denial letters, explanations of benefits, and policy documents seems full of complex legal terms and technical jargon for most people. 

This is usually by design to subtly discourage policyholders from proceeding with the appeal process. The decisions made by Aetna and other big insurance companies are often not even reviewed by an actual person, but are flagged by an algorithm, making the process feel both impersonal and bureaucratic. A denial shifts the burden onto you and your doctor to prove why a service, procedure, or treatment should be covered. While it seems as though the cards are stacked against you, you do have rights, but those rights require action. 

Under both federal and state laws, you have the right to challenge a decision made by your insurer. You have the right to file an internal appeal, and if that appeal is unsuccessful, you have the right to file an external review. You can seek assistance from the California Department of Insurance or through a private attorney. You have the right to have a physician or an attorney advocate on your behalf throughout the entire process. You have the right to a comprehensive letter of denial that tells you why your claim was denied and includes information regarding your right to appeal.  

How Do I File a Complaint and Internal Appeal Against Aetna?

To start the internal appeal process with Aetna, you can call member services, using the number on your member card. You can also fill out and submit an online form or download a printable form to mail or fax. You must initiate the process with the timeline specified in your plan documents. For urgent situations, you have the right to an expedited appeal. If you have a complaint regarding the quality of care, you can call the customer service number or use the complaint and appeal forms online for non-Medicare plans. 

When you file your internal appeal, it is always a good idea to include a letter from your doctor that thoroughly details why the specific treatment or procedure is necessary for your health. You will also include all documentation related to the claim, including medical records, and all correspondence relating to your claim. If a delay could seriously risk your life, health, or recovery, you can request an expedited appeal. Decisions for expedited appeals are generally made within 72 hours. 

If My Aetna Internal Appeal is Unsuccessful, How Do I File an External Review in California?

If Aetna denies your internal appeal, you can file an external review by submitting a written request to the address on your final Aetna denial letter. This letter should also state the deadlines for filing the external review. You may need to file with the California Department of Managed Health Care, depending on what type of insurance plan you have. The instructions and application forms for filing with DMHC can be found online. The Aetna External Review Request Form can also be downloaded if one was not provided in your denial letter. 

You must sign the consent form to consent to the release of your confidential medical information to the independent review organization. A copy of your denial letter from Aetna should be included, along with all other relevant information such as medical records and letters from your doctor. If your situation is urgent, you can file an expedited external review request. 

What are the Time Limits for Appealing an Aetna Denial?

Typically, you will have 180 days from the date you receive your initial denial letter from Aetna to file an internal appeal. That said, the sooner you file your appeal, the sooner you will have a decision. Check your plan documents and your denial letter to make sure you are clear on the time limits, because some plans have a limit of 60 days rather than 180 days. If you miss the deadline, you may lose your right to an external review. 

How Do I Fight a Big Company Like Aetna?

To successfully fight a big insurance company like California Aetna, you must follow a structured process of internal appeals, state-level complaints, and external independent reviews. Meticulously document everything, and, when necessary, escalate your case to legal action. A well-documented case and an experienced insurance claim denial attorney are your strongest assets. A communications log can detail every phone call, including the date, time, and the full name of the Aetna representative you spoke with. 

Write down what you spoke about – in detail – and any advice they provided. Make sure you have copies of your full insurance policy and your Summary and Benefits Coverage, as well as your denial letter and Explanation of Benefits. Having a highly skilled insurance claim denial attorney is virtually always your best course of action because insurance bad faith attorneys specialize in complex cases against large insurance companies like Aetna.   

What paperwork do I need when filing an appeal for a claim denial?

It is important that you keep copies of all information related to your claim and to the denial of that claim. You will definitely need your Explanation of Benefits letter which details what payment or services were denied. Keep a copy of the request for internal appeal that you send to your doctor, as well as any documents sent to the insurer and a copy of any letter or form you sign if you choose to have an attorney file your appeal for you. Keep all originals for yourself and submit copies to the insurer. Keep a log of notes and dates from any phone conversations you have with your insurer or your doctor relating to your appeal. These notes should include the name of the person you talked to, the date and time, and details of the conversation.

What types of claim denials can be appealed?

You can file an internal appeal to Aetna if the company denies payment for a health care service you believe should be covered. Denials that state your service is not a covered service can be appealed, as can a denial that claims your medical problem began prior to your joining Aetna. If your claim denial was because the requested service or treatment is considered experimental or not medically necessary, you can appeal those decisions. Finally, if your denial states you are no longer enrolled or eligible to be enrolled in your Aetna health plan or that Aetna is revoking or canceling your coverage, claiming you gave false or incomplete information, you can appeal these decisions.

What types of claim denials can go to external review?

Any denial that involves medical necessity, effectiveness of a covered benefit, level of care, health care setting, or appropriateness can go to an external review. Any denial involving an experimental treatment can go to external review, and any rescission of coverage can go to the external review.

How Can an Attorney Help Me if My Claim Has Been Denied by Aetna?

There are many ways that an experienced insurance claim denial lawyer from the Law Offices of Scott Glovsky can help you following a denied claim by Aetna. Scott can help you navigate the complex appeal process, gathering all crucial evidence and understanding the legal and procedural requirements. We will analyze your denial, build a strong case with new evidence, draft a clear and detailed appeal letter, and even take Aetna to court if the appeal process is unsuccessful. 

Since you only have one chance to submit a comprehensive internal appeal, having an attorney who is familiar with the specific Aetna requirements and all deadlines related to internal and external appeals is crucial. Attorney Glovsky will draft a compelling, detailed, persuasive appeal letter that directly addresses all issues raised in the denial letter from Aetna. If your appeal is denied, your attorney can represent you in future steps, including filing a lawsuit against Aetna to have a judge review your claim. 

 

Understanding Your Rights as an Aetna Policyholder

Having health insurance often gives people a sense of security, as it seemingly guarantees that they would be able to see a doctor and afford proper medical care if they ever needed it. However, if a health insurance claim is denied, it is important for individuals to understand their rights.

Generally, insured individuals have the right to:

  • Information about why their claim or health care coverage was denied
  • A right to examine and respond to all information used in Aetna’s internal appeal decision
  • A right to engage in an independent review of the appeal

A Los Angeles Aetna health insurance denial lawyer can help protect your rights while advocating for you.

News Related to Aetna

In late 2018, Aetna and CVS completed a $70 billion dollar merger. This “megamerger” which had been rumored since late 2017, capped off an eventful year for both companies. The combination of a pharmacy giant and one of the “Big 5” insurers will likely have significant ramifications on a number of healthcare aspects. The CEO of CVS stated that the combined capabilities of the two organizations could literally transform the consumer health experience. While the megamerger received DOJ approval, both companies were required to satisfy certain parameters, including Aetna’s sale of its Medicaid Part D to WellCare. California also required the companies to give $240 million to the state’s healthcare infrastructure, as well as to guarantee there would not be a rise in premium rates because of the merger.

News on the Law Offices of Scott Glovsky Gillen Washington v. Aetna Case

In the lawsuit Gillen Washington v. Aetna, the Law Offices of Scott Glovsky sued Aetna for not covering Washington’s IVIG treatment. We sued Aetna for bad faith and breach of contract because this denial caused a life-threatening injury. Washington needed IVIG (intravenous immunoglobulin) because he suffered from CVID (common variable immune deficiency). Although Aetna eventually settled this case, it initially denied any misconduct.

Washington v. Aetna Received National Media Attention

Scott Glovsky deposed Aetna’s former medical director Dr. Jay Ken Iinuma. In this deposition, Iinuma admitted he did not review medical records while reviewing patient claim requests. He acknowledged that he relied on a nurse’s recommendation and summary. In fact, Iinuma admitted that this is how he was trained. He said that he did not look at medical records throughout his term with the company.

Iinuma’s deposition received national media attention. After all, how can a medical director deny claims when he never reviewed medical records? His admission led to investigations of Aetna by the United States Senate, California’s Department of Insurance and California’s Department of Managed Healthcare. In addition, Colorado, Washington and Connecticut state regulators opened investigations into Aetna’s practices. Articles about this case and investigations that followed are below.

Read Our News Updates on Aetna

How Scott Glovsky Can Help if You’ve Had an Aetna Coverage Denial

Most of us expect our health insurance company to provide the services they have promised to provide, including paying for medical emergencies (including ER visits), or paying for tests, treatments, and medications when you are ill. Unfortunately, health insurance companies like Aetna seem to always be looking for a way to deny coverage, thereby increasing their own profits.  Scott Glovsky is the Aetna health insurance denial lawyer you need in your corner when it comes time to fight the insurance company.

Scott Glovsky exposed Aetna’s review practices of medical directors not reviewing medical records before denying treatment through litigation that led to national news and investigations into Aetna by the United States Senate, California Department of Managed Health Care, California Department of Insurance, Colorado state regulators, Washington state regulators, and Connecticut state regulators.

For more information you can see these articles: Aetna settles suit alleging claim-denying medical director never read patient’s records; Leading Senate Democrats want answers from Aetna CEO; California launches investigation following stunning admission by Aetna medical director; Aetna inquiry widens over ex-medical director’s comments;  When insurers require patients to stop treatment.

Scott Glovsky can file an appeal with the internal processes of Aetna, create a case before the state’s review board, or take your case to court to enforce a policy. If Aetna denied your health insurance claim, contact the Law Offices of Scott Glovsky today to find out how we can help you during this difficult time. We want to make sure you get the treatment you need, while also making sure Aetna provides the coverage you were promised.

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Scott began representing policyholders instead of insurance companies in 1999 and has consistently sought justice for his clients in ways other firms cannot. Scott is passionate about helping policyholders obtain treatments, coverage, and reimbursement from California insurance companies, including Aetna, Anthem Blue Cross, Blue Shield of California, Health Net, Kaiser Permanente UnitedHealthcare, and other companies providing insurance.

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