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Aetna / Denial of coverage

1 United States Review updated:

I have so-called health insurance with Aetna. Several weeks ago I had to see my ophthalmologist for certain symptoms which she diagnosed as punctate keratitis, conjuncitivitis, and severe dry eye syndrome in both eyes. As part of the treatment she inserted plugs in the lower tear ducts of both eyes to help with the dryness and help retain the prescribed steroid drops in the eyes. Aetna refused to pay for the procedures, saying that they violated the ban on multiple surgical procedures in one visit. Instead, Aetna paid a much lower amount towards the cost of the plug for one eye. Now I'm stuck with $250 to pay for the plug on one eye.

Oh, was I supposed to choose WHICH eye to treat that day and forego treatment on the other until another day? Was I supposed to incur charges for an additional office visit? Aetna must be one of the worst insurance companies in the U.S.

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Comments

  • Bo
      18th of Aug, 2009
    0 Votes

    I hear you. Aetna is one of the worst health insurance companies in this nation.

    I had major orthopedic surgery six months ago while covered by Aetna. I incurred several complications ranging from blood clots to tendinitis that prevented any and all movement. Aetna refused to pay for additional physical therapy visits. After three months, Aetna deems physical therapy for people with my condition "not medically necessary." I guess it's not enough that one of my shoulders is half the size of the other.

  • Ma
      27th of Aug, 2009
    +1 Votes
    Aetna - mental health benefits
    aetna
    United States

    my daugter's health is jepordized because her aetna policy won't cover anymoremental health benefits

  • Li
      15th of Nov, 2009
    +2 Votes

    Aetna apparently views any visit after 25 for physical therapy "not medically necessary". Even though my plan says I can have up to 60 visits. I guess it's "not medically necessary" to be able to walk or exercise. Why is 25 the magic number?
    I've requested an appealed for their denial of my claims and they denied it. I'm going to keep requesting an appeal and be a pain in their ###. I'm sure they will keep denying it but at least I'll make my point.
    I hope everyone will at least try to appeal their denials. I really feel like the little man fighting a giant.

  • Co
      15th of Feb, 2010
    0 Votes

    I WORK in ophthalmology and have NEVER seen punctal plugs put in ONE EYE AT A TIME...(unless it were an one eyed patient...)

  • Le
      5th of Mar, 2010
    0 Votes

    Working in a physical therapy clinic, we come accross this problem everyday. Aetna reviews for medical necessity after the 25th visit. In the past years that we have been dealing with Aetna, they have N E V E R paid after the 25th visit. All claims have been denied no matter how many appeals were sent. Even if your policy states "unlimited physical therapy benefits", they still deny after the 25th. This should totally be illegal. Aetna should make it known to their policyholders that even though they have unlimited physical therapy benefits, they will NOT reimburse after the 25th. I would love to know how much their medical reviewers are getting paid to deny the claims.

    I totally agree with "cornczech"...The patient has to continue to be a "pain in their ###". Go to your human resources person, supervisor, boss...CONGRESSMAN...Make sure you FILE A COMPLAINT WITH YOUR STATE BOARD OF INSURANCE. (Especially if your company is self-insured and Aetna is handling their money..UNBELIEVABLE). Be a pest and be loud! This has to stop.

    Unfortunately, I have Aetna, too. Luckily, I'm in a great place to have physical therapy.

    GOOD LUCK and don't give up. We need to all get together and STOP THIS ABUSE

  • Gm
      31st of Mar, 2010
    +2 Votes

    I was just denied coverage for back surgery (lumbar fusion). I have multiple conditions including demylenating poly neuropathy, osteoarthritis, spinal stenosis, previous lamenectomy, discectomy, etc...

    I called Aetna and asked why I was denied - they stated that I should have a more conservative procedure like physical therapy. I can't walk for more than 15 minutes, sit for more than 20 minutes and can't lie in bed for more than four hours. They want me to have physical thereapy!

    I will contact my STATE BOARD OF INSURANCE and make sure I give them a copy of these compaints along with mine.

    Oh, and my insurance is SELF FUNDED!!

  • Sp
      5th of May, 2010
    0 Votes

    My Aetna summary plan description clearly states that 60 visits per year are covered for physical therapy. Nowhere does it state that after 25 visits the PT would be subject to medical review. I underwent radial head surgery on New Year's eve and have undergone painful and progressively active-assisted physical therapy since mid Jan. I have not reached my maximum medical improvement nor my max of 60 days. Aetna's online claim tracker shows checks issued to my physical therapy office. However, last Friday I receive a letter that RETROACTIVELY denies payment for my physical therapy after March 8 based on a Clinical Bulletin that is not referenced in my summary plan description nor was ever mentioned when the member services told my PT office that I was covered for 60 visits prior to my even starting physical therapy. Aetna's plan misrepresents its coverage and to my detriment I relied on their written words and issuance of checks. It isn't a new tactic, on Oct 24, 2003, Aetna settled a federal lawsuit with doctors over the same issues. I am appealing as high as I can go, but I can't even reach a case manager cuz they hide behind their automated phnoe system.

    According to a report on the lawsuit: The settlement requires changes and commitments in Aetna's business practices to eliminate "the worst of the improper practices involved in managed care." Among the changes, which will affect all doctors treating Aetna patients:

    Eliminating downloading and improper bundling and computerized denial practices.
    Establishing the standard of a "physician, exercising prudential clinical judgment" for "medically necessary services, and allowing cost to be considered only when an alternative service is at least as likely to produce equivalent results."
    Creating a dispute-resolution procedure, using an independent external review of decisions regarding medical necessity.
    Providing a facilitator to assist physicians in enforcing the agreement.
    Creating a $100 million fund for physicians to recover some of their damages.
    Establishing a foundation "dedicated to promoting high-quality health care."
    The agreement also requires Aetna to pay lawyers representing the doctors $50 million in attorney's fees, including $6.5 million in expenses.

  • Ja
      25th of Jun, 2010
    0 Votes

    Whenever there is ANY issue you should 1st call your PLAN SPONSOR'S REPRESENTATIVE.
    You can call your human resources department of the employer the AETNA insurance is through.
    Ask for the insurance benefits specialist & ask them why your employer chose AETNA - explain how
    they may not want to go with AETNA as an option for the next open benefits registration.

    The liason may be able to get some action.
    This really freaks out everyone at AETNA because they risk losing the contract ;)

    You can also keep going to the ER ;)

  • Ga
      18th of Aug, 2010
    +1 Votes
    Aetna - won't pay for basic policy contract
    Aetna
    Austin
    Texas
    United States

    Aetna won't even pay for basic coverage of primary care physicians in my plan coverage. That's not anything special, I am talking about just going to the primary care physican, they won't even pay my claim for regular doctor visits.
    Aetna SUCKS.

  • Si
      2nd of May, 2011
    0 Votes
    Aetna - Long Term Disability
    AETNA
    hartford ct
    United States
    Phone: 8664441012
    aetna.com

    AETNA does not pay LTD. They are in the business of denying claims. Please take a look at complain board.

  • Si
      2nd of May, 2011
    +2 Votes

    I am currently fighting with AETNA ! Ebony Doctor is the 4th person to handle my case. According to her my Dr. has not sent the correct paperwork, but my Dr. said he has never received a request for any xrays, MRI's or cat scans. I think this is their game. They say" we don't have the correct paperwork" but they simply don't asked for it! My Dr. told me they have played this "game" with him and several of his patients for years now. My Dr. spoke to one of "their Doctors" on the phone and he totally discredited him more or less told him in so many words he was wrong about his diagnosis and treatment. I have had two surgery's and a third forthcoming. I have spoke to three managers, but I just found out that two of the "managers" were not they lied, they were just reps. I even had a "manager "named Wanda that gave me some bull story about how a whole panel of people( like a review board) would be making the final decision on whether or not they will continue my pay after May 9th 2011. I again just found out that is a bold face lie as well, a rep just told me it is Ebony Doctors decision alone! Ebony is not a doctor. not a nurse. has no medical degree of any type. I guess it's just up to her weather I loose my home, car everything. I am a single mother of two that has been with Bank of America for 18 years, yes 18years I have paid for LTD just in case something happened to me my children and I could survive. I suffer with great depression and pray many times daily. I pray for all of you as well. Unfortunately it's all about the all mighty dollar, and no they don't give a ###. why would they? It's not them or their wives or mother or child right? I wonder what happens when AETNA employees get hurt? Would they deny their own? I hope they never have to miss a bar b que or a graduation or a wedding because they are laying in bed in pain. I am optimistic though I have sent medical proof of my disability and with another surgry on the calander I'm sure they will continue my 60%. I will update as soon as I hear back . Good luck to all of you .

  • Bu
      26th of Jun, 2011
    0 Votes

    http://www.diattorney.com/

  • Ta
      8th of Dec, 2014
    0 Votes

    I am a 42 year old female who has had insurance since I was 18 years old. I've been covered by varipus plans ranging from Cigna to BCBS and I can say with confidence I have never had a more shoddy, patient/claim unfriendly, unproductive plan as Aetna. Nearly every visit to anywhere resulted in a denial of payment, which resulted in a letter to me from the provider of balance due, which resulted in my having to take time to call the insurance, wait on hold, jot down numbers, make return calls in some instances and basically coordinate payment. In truth, Aetna should have been paying ME for working. This is clearly a tactic to save money, banking on the patients who lack the knowhow, patience and/or determination to go the distance and hold these scheisters accountable for a service that has been paid for, but not received. Seeing the large amounts of complaints on here, I see this review will come as no surprise

  • Sc
      11th of Mar, 2015
    0 Votes

    I have been trying to get three claims from 2013 resolved for the past almost two year. The provider is in network but used an out of network TIN. I've been told that all hte information has been corrected and the claims will be reprocessed several times. Now I'm told that the claims are too old to reprocess. I get thet mistakes occur. However, I trust people to fix their mistakes and this one is strictly now an AETNA issue. The reprocessing of the corrected claims is in a loop of rejection - for over 18 months.

  • Kr
      22nd of Jul, 2015
    0 Votes

    It's 2015 and I'm a 52 year old woman. I was a dancer, a snowboarder and a very active person until I started having back issues in 2011. In 2013 my Husbands new employer gave us Health insurance through Aetna. This employer hired a Benefits Managing company to handle all benefits for employee's and their families. I was seeing a Physical Therapist pretty much every week once a week from Dec 2013 until April 2015 and it was helping. I had to stop because Aetna cut me off. They decided I should not get PT any longer. They decided I'd had enough and that I don't need it any more, or I'm abusing it (like I LOVE having to go to the PT every week to feel good...) that I "Should" be better...I could SCREAM with frustration at this situation!! I just want to say, WHAT. THE. FRACK!? We pay a pretty penny for health insurance every month. Am I suppose to feel bad for saying this makes me mad because Aetna IS covering my other issues? AM I suppose to say, "Oh well, It's MY fault I have a ailments and I'm LUCKY...lucky me...they're covering the other ailments, so just buck it up?"
    I feel completely dehumanized. I ALMOSt feel like a factory farmed animal. I don't count, I'm just a policy number "bucking up" alright.. as far as THEY're CONcerned, I'm "bucking up" THEIR money! Clearly it's costing Aetna TOO Much to money to keep me healthy and not in pain.
    what is there to do?? I literally feel like this world is a lost cause and it's Big Pharma and Big Insurance Companies (among others) who are indeed conducting "death panels". it's not a "political thing" at ALL, it's a $$$$$$ MOney Thing.
    This is a great venue to vent to, but, honestly, is anyone at Aetna going to see this? DO they even give a crap? ahhh what's worse Aetan or Reality?

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