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Aetna / Bad Faith Disability Claims Handling

1 VA, United States Review updated:

My disability income was unlawfully cut off in February--Aetna claimed they performed a peer review, but they did not according to my doctors! Consequently, I have not been able to get the medical care and pain medications that I need and I do not have the money for my rent or other costs of living. I thought that my employer would reward all the extra hours I put in on all those extra projects. I have had two major surgeries in which a bone in my foot and my hand had to be sawed in two and there has been a delayed union in at least one of these body parts. I still need additional minor surgery on my left and right hands before I am physically able to return to work.

I need someone to get Aetna to pay for the last few weeks of my Short Term Disability claim so that I can be healed completely and it won't hurt so much! I have had months of intense suffering and isolation in addition to a severely reduced income and all my savings is depleted. They said my Long Term Disability claim was approved for six months in a letter I received dated 3/24/09, but a week later after I called them and told them that since they approved the Long Term Disability claim, then they need to reverse their decision on my Short Term Claim, now Aetna is saying it is only "tentative" and only for "two months" versus the six months that is stated in their letter and on the Aetna Workability Absence Management web site. They are also asking for more documentation and they do not need more documentation for the initial authorization of a claim because I already submitted this by their 2/28 deadline! Only after a claim is initially approved, it says in the letter from Aetna that they will periodically request more documentation in order to recertify the claim. I am ready to notify the media and other authorities if Aetna does not pay me the disability income I earned and deserve for all the extra hours I put in to make the extra projects for my employer a success! I also cannot understand why I was given another extra project after I had informed my company management that I had been to see an orthopedic hand surgeon!!

I would really appreciate anything you can do to help me in this regard. The Aetna Short Terms Claims Adjuster name is Jackie Quinones and she can be reached at: quinonesj@aetna.com. If I cannot find some way to persuade her to process my claims in a "good faith" manner, then I would urgently need financial assistance.

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Comments

In
  21st of May, 2009
0 Votes

Payment of premium does not entitle you to benefits automatically. When you enroll in your employer sponsored benefits you should; at minimum read the summary plan description, or at least request a certificate of coverage. The certificate of coverage is a duplicate of the policy document that you are covered under. Your policy language supercedes any verbal statement or inferred deduction provided to you or derived on your own.

When you file a claim, you are required to prove your loss, also known as "proof of loss." As it pertains to disability insurance, you are required to submit objective clinical findings that support the basis of your claim. Just because your health care provider tells you that you are not able to work, you are not necessarily disabled. Your contract defines your disability as it relates to your occupation. E.G. if you are a secretary you are in a sedentary occupation and your 'disability' must preclude you from performing the material duties of your own occupation. If you have a sprained ankle and you are a secretary, you are not disabled. You are able to perform the material duties of your own occupation. If you have a sprained ankle and you are a carpenter, then you are disabled from the material duties of your own occupation. Inability to get to and from your occupation does not preclude you from actually doing your job. Not being able to physically do your job does preclude you from working.

I work in disability for an insurance company and if I could tell people two things it would be:

1) read your certificate of coverage, not just the summary plan description
and
2) your payment of premiums for X number of years does not automatically entitle you to any benefit under the policy if you cannot "prove your loss" as the contract you are covered under defines "loss."

Get an attorney and spend the limited resources you have if you must, but the burden of proof lies on you, the claimant. "Good faith" lies in your understanding of the contract language of your policy and your adherence to those requirements. Insurance companies are well covered and the people they hire to administer your claims are well qualified. Chances are if you've been denied and your appeals have been denied...you haven't met the contractual requirements.

There's your assistance.

Of
  11th of Jun, 2009
0 Votes

I think you provided a very detailed informative response. Not being able to work does not a disability make. However, it is very frustrating to be "almost" well and the pay stops.

H8
  22nd of Nov, 2009
0 Votes

I disagree with the "insurance person" comment above.. READ ON...

AETNA has the worst disability claims analysts i've ever seen and dealt with... they are rude, liers, and just deny claims so they don't have to pay out, and side w/ whoever the company you work for...
they take their time and extend the appeals because they are too lazy to get it done right away.. I don't think the disability analyts there are qualified at all...
they also seem to take alot of days off, switch from one analyst to another...to another... why? because one can't handle the claim so they need to pass it on? that makes me laugh...qualified my butt...

THIS IS MY STORY AND WHAT HAPPENED TO ME...
I submitted my leave of absence on Aetna's workability management also, it told me i qualified for short term disability..
i printed out the papers needed to be filled out and when done, had them faxed to Aetna...
Aetna they said they never recieved the certificate from my provider..about a week later i was told this..
when they got the "2'nd" one, they denied my short term disability because my "INTERNAL MEDICINE DR" put on the certificate i had chronic depression, he had referred me to a specialist dealing w/ behavioral health, so i made the appt. and she diagnosed me with Biploar depression after i told her ALL the same symptoms to my INTERNAL DOCTOR..
he had no idea i had the bipolar part..

so i appealed it, they said wait 45 days..so i did and sent in more info they needed
then they had to "EXTEND" it... why? I sent in a letter related to my dr. appts. i had before i went on leave and after i went on leave, copies of proof, my dr. also sent in notes from those appts.
so...THEY HAD TO EXTEND ANOTHER 45 DAYS BECAUSE OF THOSE 5 OR 6 PAGES... come on... do your work right and stop being lazy and just putting it off...

SO... they did the peer report, calling my dr. and my behavioral health dr.. that i STILL see every week, along with my meds. dr..
my "INTERNAL DR." told them i was acting "NORMAL"
even after i told him my symptoms i had and it was all caused from work and the managers being unprofessional, saying things to me that should have never been said, gettin me upset, angry, crying, anxiety, etc...AND I COULD NOT PERFORM MY JOB DUTIES/HANDLE THEM...
as a result from those events and other things... i ended up depressed which turned into bipolar, real bad, was told it was manic depression also...

i was out from May 2009 until Oct. 09
i got NO benefits or payments, all my bills got behind, credit cards not being paid, had to cancel some of them and now my credit report is bad...

my appeal was only part of my leave, they denied me from May 13'th 09 to June 10'th 09 because my first appt. with my behavioral health dr. was on June 11'th 09..
so the approved part of my short term disability was approved from June 11'th on until i went back to work... which was Oct. 2nd 09

But...after my appeal was decided on Oct. 15'th or so...they denied me again because of what my INTERNAL DR. said, i was acting normal...which i wasn't...

the Aetna "DISABILITY ANALYST" named "TABITHA" kept telling me since Aug. 09 another week, another week or so before the decision, etc...
SHE LIED TO ME!!!
so i cried, my boyfriend came home, saw how upset i was and called "TABITHA"
SHE WAS RUDE, LIED, and then told him/me on speaker phone "NOT TO CALL BACK UNTIL OCT. 15'TH 09"


I had asked her in another call pryer to that one how my benifits would be paid out if my appeal was denied or approved, since i was "APPROVED" for the Short Term Disability from June 11'th on...
SHE SAID SHE DIDN'T KNOW...
WELL... this is what she should've told me because she should've known, and i didn't know until Oct. 15'th when they denied my appeal again...and when i got the denial letter and their " FINDINGS" which was the "ACTING NORMAL" part...

According to my place of employment... which is...of all the places... "BANK OF AMERICA"
do you know what their policy procedures for their "ASSOCIATES" are??

YOU CAN NOT GO FROM AN "UNPAID" MEDICAL LEAVE...TO A "PAID" MEDICAL LEAVE..

I had no clue until i got that denial letter, didn't understand and called "TABITHA"
SHE THEN TOLD ME I WOULD RECEIVE "NOTHING"
NO BENIFITS PAID OUT...
EVEN THOUGH I WAS "APPROVED FOR SHORT TERM DISABILITY FROM JUNE ON...

I called what is known as "advice and counseling" for the Bank of America, that lady told me Aetna should've known that and told me..
Advice and counseling did nothing to help me, that was in Oct. 09 after my denial letter and talking to "TABITHA" from Aetna.


SO... because they took so long on my appeal, extending it, and no benefits paid, i had to "FORCE" myself to go back to the same place that caused me to not being able to perform my job as i couldn't concentrate, focus, i cried, got angry, irritated, anxiety, dropped work a few times that was done and had to put in order again...
i lost my regular position because "BY LAW" bank of america can do that after 16 weeks on medical leave...

i was still angry and upset and worse because i was put in a position again that i could not do before "a processor", as a result given the "workflow" one that i did before my leave... that i was outcasted from...why? Because i have Tendinitis in my hands that prevent me from getting my "numbers" or "quota" for what i do..which is check processor/ check encoding...like data entry..

I know i did very good on my job, all the trianees told me i did, and i helped them more than "others" who should have, taking on their responsabilities as they weren't, and causing me my symptoms also..
workflow is only supposed to get the work, pass it out, pick up the done work, and bring to the next department..
that's all i was supposed to do...not required to answer the trainee's questions or if they needed help..that is a "TRAINER" position..
i was NOT a trainer...but doing their job on top of mine...

SO... by the 2nd day i was back to work, i cried at my machine, got racing thoughts...and still to this day, put in the training room where i worked doing workflow and watching how they "CHANGED" things in that room while i was gone to get better, which shoud've been done before i left...
and seeing the "new person" doing "MY JOB" that i had for over 3 years...
i get angrier and angrier and cry everyday that i am there...
i get frustrated and in pain from my hands hurting, doing more damage... and not able to get the "1600" items per hour...

A NEW MANAGER TOOK OVER AND MADE THE CHANGES WHILE I WAS OUT..

I HAVE TALKED TO HIM A FEW WEEKS AGO, TOLD HIM MY SITUATION AND MY DISABILTY AND THINGS THAT "HAPPENED" AS A RESULT OF MY LEAVE...
I ALSO TOLD HIM I CANNOT BE IN THE TRAINING ROOM BECAUSE I AM SURROUNDED BY PEOPLE THERE WHO CAUSED ME DAMAGE, AND THE NEW WORKFLOW PERSON, GETTING ME UPSET/ANGRY, WATCHING...AND CRYING
I TOLD HIM I NEED TO GO TO THE PROCESSING FLOOR "A UNIT" SO I CAN TRY AND SEE WHAT HAPPENS...
HIS QUESTION..."WHAT ARE YOUR NUMBERS?" NICE HUH?
I CAN'T GET MY NUMBERS...CAN ONLY DO "1300-1400" AVERAGE..
I WILL EVENTUALLY BE PUT ON WARNINGS.. THEN BOOTED OUT OF THE COMPANY AS MANY OTHERS HAVE...

I WAS JUST TOLD THIS PAST FRIDAY 11/20/09 THAT I WILL BE MOVED TO A UNIT, AFTER A WEEK OF WAITING.. IN THE FIRST WEEK OF DECEMBER..
ANOTHER WEEK OF TORTURE BECAUSE OF THE HOLIDAY THIS THURS...

SHAME ON AETNA FOR LYING TO ME...TAKING THEIR SWEET TIME, NOT TELLING ME THE RIGHT THINGS THEY SHOULD HAVE, SHAME ON THEM FOR MAKING ME WORSE...EVEN TO THIS DAY...CRYING, GETTING ANGRY STILL AT WORK, ETC.. I FEEL IT WAS "BAD FAITH" ON THEIR PART, AND BY GOING BY WHAT MY INTERNAL MEDICINE DR. SAID..
WHEN THEY SHOULD'VE GONE BY MY BEHAVIORAL HEALTH DR. DIAGNOSED ME AS...
FORCING ME TO GO BACK BECAUSE OF THEIR LAZINESS AND NOT DOING THEIR JOB RIGHT...

I NEED MONEY FOR ALL THE NECESSARY THINGS I NEED, SUCH AS MY APPTS. WEEKLY, MY MEDS MONTHLY... LAMICTAL AND STRATTERA, AND OTHER MEDS I TRIED SINCE JUNE TO GET THE RIGHT ONES..
I NEED GAS IN MY CAR, INSURANCE, BILLS, FOOD, RENT, TO PAY MY SHARE W/ MY BOYFRIEND.. ETC..
MY BOYFRIEND ENDED UP PAYING FOR THINGS THAT I COULDN'T, I OWE HIM SO MUCH NOW..
IT PUT US ON A TIGHT BUDGET; ME TAKING OUT OF MY 401K TO PAY FOR WHAT I COULD UNTIL THAT WAS GONE..
I HAD TO PAY COBRA $100 A MONTH TO KEEP MY AETNA "HEALTH" INSURANCE IN ORDER TO GO TO MY BEHAVIORAL HEALTH DR. AS THEY DON'T TAKE "STATE" MEDICAL...
AND I WAS NOT ABOUT TO SWITCH TO ANOTHER FACILITY AND START "OVER" W/ ANOTHER DR OR PLACE..
I AM STILL WORKING ON GETTING THE STRATTERA DOSAGE RIGHT, AND LAMICTAL BEING INCREASED SLOWLY...AND GETTING BETTER, BUT IT'S STILL HARD..

COME ON AETNA...DO YOUR JOB RIGHT, AND MAYBE YOU WON'T GET SO MANY COMPLAINTS..
BECAUSE I'VE READ SO MANY OF THEM, AND CAN RELATE TO SOME.. I WONDER HOW MANY "BAD FAITH" LAWSUITS YOU HAVE AGAINST YOU...

AND AS FOR MY EMPLOYER.. SHAME ON YOU TOO...WE'LL JUST HAVE TO SEE WHAT HAPPENS, BECAUSE BANK OF AMERICA ALSO HAS NUMEROUS COMPLAINTS...FROM "ASSOCIATES" CALLING HR AND COMPLAINING W/ NOTHING GETTING DONE BEFORE I WENT ON LEAVE...UNTIL THE NEW MANAGER STEPPED IN...

BANK OF AMERICA SEEMS TO ALSO CARE MORE ABOUT THE PEOPLE THAT HOLD BANK ACCOUNTS/CLIENTS, THEN THEY DO FOR THEY'RE OWN ASSOCIATES..

AS FOR BOTH AETNA AND BANK OF AMERICA, I WILL TRY AND FIND AN ATTORNEY HERE IN CONNECTICUT TO HELP BRING THIS TO COURT AND "SUE" FOR DAMAGES THEY CAUSED AND STILL ARE...

I CAN'T QUIT BECAUSE I NEED MONEY, NOT IN THE RIGHT STATE OF MIND FOR AN "INTERVIEW" WITH A NEW JOB...

IF I CANNOT FIND SOMEONE TO HELP ME, I WILL FILE ON MY OWN TO CIVIL COURT...SEND LTRS TO CORPERATE OFFICES, NEWSPAPERS, MEDIA... ETC...

HECK, I THINK I'M GONNA COPY AND PASTE THIS AND SAVE IT...

WHAT GOES AROUND, COMES AROUND...
I WILL GET WHAT I DESERVE BECAUSE OF THEIR "ACTIONS" AND DAMAGES...
COUNT ON IT...EVERYONE WILL KNOW ABOUT THESE TWO "COMPANIES"

ANY ATTTNORY WHO MAY READ THIS AND WOULD LIKE TO HELP ME... PLEASE RESPOND TO THIS AND TELL ME WHAT I CAN DO, OR WHAT I SHOULD/SHOULD'T DO I WOULD APPRECIATE IT..
WRITE YOUR NAME/NUMBER AND IF YOU'RE INTERESTED AND IF I HAVE A GOOD CASE ON MY HANDS..

HAVE A NICE DAY TO THOSE WHO "DESTROY" OTHERS...
BECAUSE SOMEDAY " I WILL"

FROM: A MANIC BIPOLAR DEPRESSION PERSON HERE IN CONNECTICUT

Jo
  13th of Dec, 2009
0 Votes

I am a former claims director with one of the largest insurance companies in America. I had a similar experience with Liberty Life Assurance Company of Boston. Deceit, incompetence, unreturned phone calls, failure to provide certificate of insurance or even the disability policy. I requested the policy over and over from the claim rep. After finally obtaining the policy two years later I reviewed it and see multiple areas of coverage that applied but were ignored by Liberty. I was deemed disabled by doctor after doctor. Liberty Life paid me monthly benefits for a period and then cut them off without even obtaining doctor reports to support their position. The claim rep continuously told me he was ordering medical reports however I found out from my treating provider that he had never sent for them. There appeals panel agreed with me and re-instated partial benefits. I have now been declared permanently disabled by Social Security. There denial and delay in handling my claim caused immense financial and mental health and medical problems and they failed to issue various other benefits outlined in my disability policy. In almost twenty years of insurance claims experience I have never seen such unprofessionalism, incompetence, mis-representation, and bad faith from an insurance company. I was fortunate in that I worked for several national companies that properly investigated and paid their claims fairly, in good faith and on time. I contacted their leadership team with my concerns and they also failed to contact me. It is truly appalling how they handle their claims. If your employer has Liberty Disability Insurance beware.

Gl
  8th of Jan, 2010
0 Votes

Everything I have read so far I am going threw right now. I live in a state that you apply for state disability and Aetna. I was denied from Aetna cause I was receiving the max from the state. My state ran out in Oct, 2009. So I called them about long term. They told me I have to receive short term before I get long term. So I had to start the process all over again in Oct. I see my Drs. reguarly for my meds, MRIs, EMGs and also I need a spinal tap. They are absolute liars when it comes to there DRs. calling your DRs. They never spoke to any of my DRs. and they insist they are a reputable co. and she doesn't know why my Drs. would not tell the truth. Although occupational health told me I am qualified for long term and she would send me a proper appeal letter and for me to state about " the Doctors "situation.

I would like to know if anyone with a complaint about Aetna has worked for Luxottica?

Sincerely, Gloria

Ca
  18th of Aug, 2011
0 Votes

i worked for aetna for 18 years as a senior medical claims examiner. they were very fair in all their dealings in the health management claim system. they paid or denied claims by a set of quidelines that were given to all employers and employee's that held our insurance. they were also handled on a timely basis. however, i went into short-term disability while working for aetna and my claims were handled adequately. after one year i went into long-term disability with very few problems. at this point i applied for social security and was denied twice. they said i could work at a lesser position. this is not true. i have severe bipolar disorder mixed with rapid cycling which does not respond well to meds. at this point, i face endless reviews on a yearly basis where they go back and forth with my doctor in an endless battle. a clerk at aetna slipped and told me in the end that my doctor has the last word. thanks, could you have told me before i had a true nervous breakdown..(ptsd).

Na
  2nd of Oct, 2012
0 Votes

It suck but the only thing you can do is exhaust your options by going through all of the appeal process. Once you've done that if your claim is still denied, the next step is to hire you and attorney. You can also report them to the insurance commissioners office in your state. When the commissioner gets enough complaints about a company and investigation is initiated. I'll tell you what my attorney told me. It sucks that you have to wait but apply for all the state benefits you qualify for, and hire an attorney. If its discovered that your claim was not handled properly a capable attorney can get you back pay, compensation for pain and suffering as well as punitive damages. Insurance companies deny claims knowing that most insurers will not got through all the loop holes and the headache of fighting the insurance. Trust me when I tell you if you do in fact have a legit bad faith claim the reward is worth the hard work. Whats the saying "nothing worth it comes easy". in ACE V AETNA LIFE INSURANCE COMPANY A jury awarded Ace $27, 000 for wrongful denial of benefits, $100, 000 for emotional distress, and $16.5 million in
punitive damages.

Mr
  6th of Feb, 2013
0 Votes

I had shoulder surgery and was approved for leave from Bank of America from 10/31/2013 to January 1 of 2013. Even though AETNA requested and received a blanket release to request whatever they needed from my Dr, they didn't request any medical records past the first month, and subsequently ceased paying my disability for the month of December. They then of course denied the appeal after their fax machine ate some of the pages and all kinds of other excuses along the way. Their appeals person, Samantha Fariello was extremely rude and outright told me that she wasn't interested in talking about what they did wrong in the first place, just the info she needed to process my appeal. What a bunch of Charlatans and cheats. My arm still isn't right. I'd like to take a bone saw to Samantha, and then tell her to get back to work processing claims in 30 days. Advice and Counsel was absolutely useless to me through Bank of America as well. I hope Bank of America dumps them like we did Blue Cross when we started doing business with these jokers in the first place.

Ha
  1st of Feb, 2016
0 Votes

I just completed a short term claim. Very slow process. Also, despite being approved and then returning to work after 5 weeks, I have only been paid for 3. I realize there was a one week offset, but because I was cleared to return to work at the end of the 5th week, there is no payment at all for that week? Good thing I had some money saved or I would be up the creek. Point is, this type of insurance can be a lifesaver or a headache.

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