Complaint Review: Aetna U.S. Healthcare - New York

It is hard for some of you to judge anyone else if you have not been in their situation. Understanding the documents provided and the fine print has nothing to do with unreceived and promised phone calls. Constant changing of information. Is that written in the fine print!!! If they need information from the consumer then why do they not ask for it. Why does the consumer constantly need to call and make sure they have what they need and what is going on? How do we know what they need unless they tell us? Why would they wait for several months and then finally tell the consumer they need a certain document. You would think they would want to process the claims as soon as possible so they can be done with it and move on to the next. Never, ever judge someone unless you have been in their shoes and know exactly what their situation is.

I think more people should dump aetna as they constanly would tell me & wife that she was not covered...... and we had to constantly tell them the correct employer. Fact is they need to seriously update their process & procedures and as a programmer of similar systems, I could offer my skills for a fee that would enable them to have proper service quality and be able to at least avoid similar issues.

Biggest problem I had with Aetna is that they would constantly put claims under a previous employer (also Aenta insurance) instead of my current, and then reject it. Nearly 80% of all claims in 2 years required me to call at times 5-10 times a week to have any claims udner previous employer reprocessed. Even 3 years later,there is now 2-3 old claims that were never submited by a now dead former doctor of mine, that they denied for similar. I came within 50 claims of filing criminal action in Oklahoma with the OKLAHOMA INSURANCE COMMISION and also various other 'violations'. I still wish I had gone ahead and sued, it would have been millions$. I actually incurred a overall debt of about $10k because of Aetna delays and related. This problem with Aetna actually indirectly caused me to have problems with my dads estate (inheritance) Because it made me look like I couldnt hand my $$ to my dad. He died 1.5 years after the problems and never understood it was AETNA not me. Unfortunately I cant fight the trust that he left, so I am stuck with how AETNA screwed me

I am a former employee of Aetna. I have been in both customer service/calls and claims and a few other depts of Aetna. Health insurance is confusing to say the least. And each call that comes in is different. I have had some really bad, abusive calls from clients. And I have had some great calls. Where I was able to help my client and their family, right there on the phone. Taking care of their issue so they did not have to call back. The employers who provide the insurance for their employees are caught between finding a decent health plan and one that will not break their business. Insurance has become an consumer driven market. Where the member must know how there benefits work. They may not like all aspects of the benefits, but knowing is 1/2 the battle. And I tell each and every one of my members that call in this. Education and knowledge is power. I would like to say, that what Jim said regarding the report being vague is correct. If I were speaking to ED in Tempe AZ on the phone, I would ask more detailed questions. Find out more facts surrounding the situation. And see if there was a way to have the claim paid in network. All information has to be considered.. And this is why I suggest educating yourself as to how your policy works. Keep your explanation of benefits, they are legal documents. Say informed as best you can. As for the 2 current Aetna employees, Have a little compassion and empathy for the members and their situations. You both probably have Aetna insurance and I am sure that you have had to call member service and discuss your own claims for what ever reason. Yes, Aetna also has to follow the guidelines that are set in place by the Dept of Insurance, Legislation, and the Federal Government. Each state has its own guidelines and laws that each Insurance company has to follow. For J.Wallace in Sacramento... Here are a few terms that I always explained to my members and even the employers. Example: of a policy. (basic type policy) PPO product, **In-Network = Contracted Providers. 500 deductable: this is the members responsibility up front. Coinsurance: 80/20 Aetna pays 80 % and Aetna pays 20% after the deductable has been met. Out of pocket max. $5000: This is your 20% tracked toward the total out of pocket of $5000. When the 5000 has been met, claims will be covered at (most, not allways) 100% of the contracted amount. ***** ** OUT-of Network = Non Contract, Dr. office will take the insurance, but, this does not mean they contract. The dr. has the right to balance bill on Out of Network claims. Again, I am not taking sides. I see both. I am sorry to all the Members that have had rude and otherwise Less than satisfactory service. I can only say for me, that I did my best when I worked there to take care of my members, and the employers that I worked with closely. Trying to keep a cool and calm, and still be able to empathize with the situation is not always easy when you are being yelled at, cursed and verbally abused. It can be very stressful at times. Just as you members have a hard time with understanding how the insurance works. Being a former employee, the office politics can be as overwhelming and stressfull. Putting all sides together sometimes is to much. Thats probably why I left. And last but not least, Remember do unto others as you would have them do unto you. Easier said than done I know. Have a nice day. C.

While the surgery was performed according to the OA within 24 hours of diagnosis, a referral was provided to a non-network provider. My question would be, was the OA admitted to a hospital immediately and stayed there until the provider surgeon came in and did the surgery or did OA go home first? Emergency proceedures covered at the higher coinsurance level would be those which are immediately life threatening and must be provided immediately. If she went home, contacted the other provider and scheduled the proceedure, then that hardly constitutes a demand for in-network coverage. If OA was immediately admitted and surgery was performed without ever leaving the facility, and met the life threatening condition, then an appeal should do the trick. Again, it is hard to tell from the original post exactly what went on there.

It's easy to call others "stupid consumers" when they get screwed over by greedy corporations which create their rules and regulations in a way were you can only make it wrong, such as health insurances. Not too long ago I went to a dentist, had a root canal done, and guess what? The insurance didn't pay the dentist !!! It was in the network, and I followed their rules as stated in my policy. Reason for them not paying??? I'm still trying to figure it out since 7 months now, as the dentist is asking for his money and the insurance is giving me the run around without any logical explanation. So while you state that we are "stupid consumers" because we can't read or understand what a policy means, just pray your God that you'll never have to rush to an emergency room or even something less dramatic, and then have your insurance company denying your claim even when you thought you knew it all !!! Trust me it happens every day with health insurances,home insurances,car insurances, all insurances, no matter how good of an interpreter you are !!!!

I've had what I consider mediocre to poor service from Aetna over the years. When I could not understand segments or clauses I called to get some clarity on issues. I have also worked in service industries most of my life. I take into account that your comments were written some time ago, but understand this, Melody, and the person who wrote the Read and Comprehend comment. Health insurance and getting coverage is in itself anxiety producing, complicated, and confusing for even the most saavy of consumers. The language of these contracts is purposely evasive and there are so many clauses, restrictions, and gray areas coupled with incompetent service people, it's a miracle if one doesn't have a problem. The reason for "fine print" is to be evasive. Contracts are supposed to be written in plain language, and the companies seem to work very hard to evade this responsiblity. One example is that in many cases concerning deductibles, Aetna refers to them as a "client responsibily" instead of just quoting a dollar amount. In the fine print or a different part of the contract it will give you a dollar amount. What you two fail to mention is that we pay for these services. I've waited 6 months to settle obvious claims, stayed on the phone for hours, waited in "queues" for just as long, dealt with untrained employees, could not speak with a supervisor, was sent to wrong doctors from unupdated lists, spoken to rudely, and given false information. If I were an employee for any of the companies I've worked for I would have been fired. Aetna and other companies that offer group plans knowing health insurance is indespensible just don't care. The deny claims, give bad service, because they can. Both your comments, especially Melody's, work toward the end of "shaming and blaming" the consumer, which is becoming more inherent in our culture and only works to bolster the company's weak excuses for non-payment. Insurance should be simple and explained in straightforward , truthful, language when in fact it is designed to avoid paying a claim or to get you to buy something without adequate knowledge of the product. How many companies have an HR person that will sit down and explain the terms of a contract? Very few. How many times during a person's employment does an employer switch providers? At least once a year. Why should we have to sweeten the pot with "honey" to get what is rightfully ours? I pay $2000 a year for three of us and our employer kicks in another $7,000. Perhaps this is a faulty analogy but if you guys leased a Ferrari and paid $9,000 every year and it kept breaking down even under warranty and the seller refused to do anything about it, or made excuses, or just refused even under the terms of the warranty, to rectify the problem would you be so quick to blame yourself. What if you had to go to hearing to get your transmission serviced? What if you had to pay to get it out of the shop until the seller made a '"determination." My guess is you would be infuriated. Imagine life your car in the shop every month, or having no car. Well, at least you'd still be alive, which is not guarantee when insurance companies refuse to act on something you've paid for and is rightfully yours. WallaceJ

Your insurance policy is your responsibility to know as a consumer. Ever heard of the fine print? People hardly ever take the time to read and think that this is like the eighties and ninties and think that they have insurance and assume that they are covered... News flash everyone, everyone, including your employer is doing everything they can to save money. However to the same token they are an extra avenue and advocate for their employees. Most human resoures have people that will explain your benefits in great detail even going as far as to call the insurance company for you or do an appeal. Noone is alone in this business. If you do not agree with what your employer has decided get together with co-workers and contact your home office, you would be suprised at what can happen with teamwork. But it still comes down to knowing your policy and your rights. A majority of the Customer Service Professionals or Service Consultants at Aetna will be more than happy to go the extra mile and tell you what you need to do, just ask, nicely. You catch more bees with honey than vinegar.

First of all, if you work for an employer that provides insurance many times you don't get to "pick and choose your policy" and what it covers. You usually get a choice of HMO or PPO, in network and out. Did you read the part of her email where it said it was "life threatening" and that surgery was performed immediately? Someones life is worth more than driving around looking for an in network doctor while the clock is ticking away. GET REAL!! Under life threatening circumstances, insurance companies need to bend and pay their claims.

I find it ridiculous people take insurance policies and do not research them. Did this person think to call Aetna prior to the services rendered? I mean if you want them to pay, call and see before hand. Ignorant people always complain when they did not take the proper steps to check and see whats up, and then cry and sue becuase of their own laziness and assumptions. Thas whats wrong with the medical society, the pateints who assume to much.

Aetna is only the administer of your claims. It is your employer who is the policyholder and they tell them how to process their claims such as in-network or out of network. You can always appeal the insurance company's decision on the outpatient surgery and they will get back to you within 60 days. Please remember that "Aetna" is following the guides as determined by your "employer".