Aetna Health Insurance

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Jennifer of Jacksonville, NC January 30, 2009

Jennifer of Jacksonville NC (01/30/09)
My 4 yr old son had an incident on 01/11/09 where we found him unconscious in his room in the middle of the night. He wasn't breathing right, had a bloody nose and did not regain consciousness for 30-45 mins. The ER doc said he needs to see a pediatric neurologist asap and thinks he had a seizure. Well there isn't one within our area that is in network (designated by aetna as within 30 miles of our home), so they told us we could choose one, which his pediatrician did, and they would get them precert as in-network.

They just told us yesterday, right before the appointment, that they will not give us precert because there is another provider in our area. The provider they are listing is over 100 miles and 2 1/2 hours away! When we called member services, they confirmed that is not what they consider in our area. The people with precert can't seem to explain why it was denied and told us they would let us know on our appeal, and we still haven't heard back on that. So now here we wait, yet more, not knowing if something serious may be wrong with our son, or when/if they will approve for him to go to someone local. They don't have any excuse for us when we quote them the plan as stated and won't give us answers.

We have had to cancel his appointment that he has had for 3 weeks now, and wait hoping they will approve the local provider soon, and that it won't be another 3 weeks before they can see us. I don't want to go to the provider and use out-of-network benefits, but I'm getting desparate for my son to see someone. I even tried to see if aetna would approve an adult neurologist (that is in-network and area), only to find out that none of them will see children under 18 yrs of age. We are very upset right now, fearing he will have another incident like before. He was completely lifeless, it was the most terrifying night of our lives, and we still don't have any answers.

Howard of La Grange, TX January 27, 2009

Howard of La Grange TX (01/27/09)
Since my wife was paid weekly, SRC originally would automatically deduct premium payments from her checks. Upon the birth of our first child, my wife stopped work temporarily, so we were required to continue making insurance payments weekly by phone. Since she's still technically on the payroll, but not salaried, we are not in a COBRA program. However, with the addition of our child, as well as the turn of the new year, the customer service employees could never figure out how much to charge our checking account.

Payments were automatically credited back to us for being either too large or too small. We then were listed as having not paid and therefor were not covered within their computer system. Suddenly our bills were coming due directly to us, and well as prescriptions being full price. Thus far I haven't been able to get a manager to call me back to ensure the bills are re-submitted. The company won't do it automatically, though it was their fault, so now I'm forced to take my time to keep calling, not to mention making back payments to get caught up.

In a related issue, they denied coverage for all charges for the birth of my son while my wife was in the delivery room at the hospital. The plan covers a certain amount for in-patient stays, but they didn't consider it in-patient until after my son was born and she was moved to the recovery room for the next two days. We now owe the hospital roughly an extra 3000.00 that should have been covered.

3000.00 plus dollars for delivery room, ? as yet to be seen for crediting back payments in wrong amounts.

Mike of Campbell, CA January 14, 2009

Mike of Campbell CA (01/14/09)
I've had problems with my shoulder for the past year. Originally it was because of nerve damage. The only treatment was physical therapy and after 2 months, Aetna said I had run out of benefits. I had to pay the next 7 months of therapy out of my pocket. After that period it was determined I needed surgery. My doctor assured me that Atena would cover my physical therapy as it was part of the overall recovery process. Guess what? Aetna declined the therapy coverage.

Calls to Aetna were useless. All I heard is that I had reached my maximum benefit limit and that was it. How can they approve a surgery and then not cover any rehab?

Joshua of Washington, DC January 12, 2009

Joshua of Washington DC (01/12/09)
They claimed that they did not file my request for a primary care physician that I then visited until after my visit, and so my visit was therefore a doctor visit without a referral. Therefore, it was counted as out-of-network and I was charged more than expected. Since I had no proof on the contrary, there was nothing I could do.

Unjustly charged 175

Patricia of Woodstock, GA January 12, 2009

Patricia of Woodstock GA (01/12/09)
My 23 year old daughter, covered under my Aetna group POS choice plan, has a sever jaw deformity with an ever growing open bite. She suffers from Severe head and jaw pain, inability to eat..now losing weight and other serious conditions resulting from this condition. The reconstructive surgery for her jaw was approved by Aetna (an in-network oral-maxillary surgeon). The surgeon will NOT perform the surgery without the services of an orthodontist to get the teeth lined up correctly and expand her very narrow palate. The orthodontic intervention before, during and after surgery meets the standard of care for orthognathic reconstructive surgery and is mandatory.

Round and round claim submissions, denials, and the denial from an appeal (the person who performs the appeal is an employee of Aetna) have left me with a staggering 4500.00 bill. Verbal approvals for service were given to our broker, which Aetna denies making. We are allowed one more appeal, but the appeal will be handled by an Aetna employee. The Aetna policy manual on orthognathic surgery and braces is vague and contridicts itself, but clearly addresses the pre-surgical orthodontics for Managed choice plans with approved surgeries.

In responding to an inquiry, made by the state Insurance Commissioners office on my behalf, Aetna's response contained several errors. e.g. The letter states that I am covered by an HMO. I am covered by a high deductible Point of Service Choice Contract. The orthodontics need to be covered under Medical benefits, as the surgery approval was for medical benefits. I would like Aetna to provide in-network coverage for the orthodontics and get the bills, which I am already paying, PAID.

1. My daughter, a full time college student, is suffering emotionally from the worry that we will have to pay for the braces. My husband has a cardiac condition (pacemaker placement is scheduled for 01-15-2009) and his only employment is a part-time position at our church. Mary's bite is worsening and she is having trouble eating. 2. We are being pressured by the orthodontist to pay his bill, and after having the initial appeal denied, are paying his bill in installments. Our budget is stretched already and the added pressure from one large unexpected bill is extreme. 3. We went ahead and had the braces put on because we were led to believe that they would be covered. We went to an in-network dentist to preclude any out-of-network denials. But Aetna has found other bases for their denials, all of which seem in error.

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