Aetna Slammed With $25.5M Verdict For Improper Claim Denials, Just Months After Medical Director Admits Never Reviewing Records

Aetna Slammed With $25.5M Verdict For Improper Claim Denials, Just Months After Medical Director Admits Never Reviewing Records

An Oklahoma jury slammed Aetna with a $25.5 Million verdict for improperly denying medical claims, awarding the family of the deceased patient $15.5 million in emotional distress and another $10 million in punitive damages. The verdict comes just months after an Aetna medical director admitted under oath, that he never actually looked at a patient’s medical records while at Aetna because it was Aetna’s protocol, and that he based his decision off “pertinent information” provided to him by a nurse.

The case details are very common and happen everyday across the nation: Patient pays for health insurance, patient gets sick and seeks treatment, insurer denies claim under the guise that services are deemed experimental or investigational. According to the family’s attorney, Doug Terry, “[this] case represents/exposes so much of what is wrong with health insurance,” Terry said.

“This case gave the jury a look behind the curtain so they could see what goes on at a health insurance company when they deny claims.  The evidence showed Aetna’s denial of her claim involved overworked, under-qualified doctors working in the interest of their employer’s bottom line who are compensated in part based on the profitability of the company.”

Court documents showed that evidence was presented to the jury, showing that Aetna’s doctors spent just minutes reviewing her case, despite the critical nature of her condition. Ultimately, Aetna’s  medical doctors denied the coverage, saying it was experimental and investigational, though clinical expert, Dr Andrew L. Chang, argued the treatment was not new, but a well established cancer treatment for decades, and had not only been approved by the Food and Drug Administration, it but is also covered by Medicare.

Interestingly, Aetna considers the treatment appropriate for pediatric patients; and Medicare pays for the treatment in 65 year olds, which raises the question: “what is it about 22-year-olds to 64-year-olds that makes proton therapy experimental? There is no good answer for that; insurance companies call it that because they decided to deem it as such.” according to Dr. Chang.

According to multiple outlets, several jurors mentioned that they believed Aetna had “Rubber Stamped” the claim denials, based on the very limited time Aetna medical doctors spent actually reviewing the claim. Ultimately, the jury found that Aetna had “recklessly disregarded its duty to deal fairly and act in good faith with the Cunninghams.

Astonishingly, Aetna’s  attorney John Shely said in closing arguments that Aetna was proud of the three medical directors who denied coverage, even turning to thank them as they sat in the front row of the courtroom, according to jurors and other witnesses in court.

According to a CNN article, this decision represents the largest verdict in an individual claim denial insurance case in Oklahoma history, and could have major ramifications across the country for a form of cancer treatment called proton beam therapy.

The Case info: Ron Cunningham et al. v. Aetna Life Insurance Company, et al; Case number CJ-2015-2826 in the District Court of Oklahoma County, State of OK

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Paul Newcomb

My claim for short term disability was denied by Aetna. It was due to the company providing me a therapist of their choosing who did not process my physician care and release statement properly. I am appealing their determination and would appreciate any help before I write an appeal.

Michele McFerran

Absolute criminals. My mother is 84, total hip replacement. All preapproved. Now they are denying her necessary physical therapy and policy of up to 20 days in skilled nursing. They are trying to send her home 5 days after her surgery. She cannot get in and out of bed alone. She lives alone, there is no one near to care for her.

My sister is planning on her being there mid October which is what the preauthorizations timed perfectly.

Linda Stanton

I work for a medical provider and Aetna is the worst insurance carrier I have to deal with. They just sent claims at random. 3 claims submitted at the same time, billed exactly the same way, one out of the denied for some bogus reason. You have to fight like a hell to get your money!! STAY AWAY! THE BIGGER THEY GET, THE WORSE IT GETS! IF YOU HAVE A CHOICE, PICK ANOTHER PLAN!!!!

    Ann R.

    I have my own company and the amount of claims I submit to Aetna and denials are ridiculous. They claim diagnosis codes are wrong, procedures are wrong, place of service is wrong?!

    Then I just have to resubmit over and over. It’s a nightmare.

Kathleen Ginty

I am so sorry for all of you. I feel almost petty compared to what you have went through but the level of stress Aetna has put our office through! We have been trying to credential and contract our providers with Aetna and it has take a year….it is unbelievable….all of the providers have an excellent record. with Our office is forced to participate because they have such a large network and so many patients who have been coming to us for years are now “victims” of an employer’s change to Aetna. The medical contracting and credentialing calls are routed to the Philippines or India. Providers are told case is still being reviewed or complete on line application…. the mysterious network manager who is nameless and doesn’t have a name will “reach out to you”. Ever subsequent call for a status…. network manager will contact you… still reviewing…. send another letter of intent…. during this period, Aetna and just assumes Doctor will see patient, patient may lay higher out of network fees but Aetna will pay less…. honestly and I don’t say this lightly …. their credentialing and contracting process can only be termed abusive. I am so sorry any member who should be treated with compassion and has the most right to expect fair dealing and compassion is treated as terribly as all of you and your families…they need to be exposed.

Michael J Katz MD

Sadly, all of you have been scammed in the name of “Cost Containment”. Aetna gives stock options to its Best Shills. The Shill who designs the denial schemes lives in a $ 9 Million Waterfront home in Newport Beach California. Your ability to claim your insurance benefit is “Contained”. The Shill’s ability to collect for cheating you is “Unlimited”.

Michael J. Katz MD FAAOS

As an example, let’s study a common Aetna ploy. The claim that they assert is that the treatment is Experimental and Investigational and therefore the policy won’t pay. As a hypothetical, let’s say that COVID 19 vaccination was a possible insurance benefit. You submit a claim for the Moderna or Pfizer vaccine. Both had emergency approval from the FDA. Using Aetna’s line of reasoning, because both vaccines hadn’t been studied as other vaccines had, Aetna considers them Experimental and Investigational. This is Pretext and is a Lie. It would be bad enough if this was an innocent mistake. This is premeditated with extensive data analytics for the sole purpose of cheating the policy holder and enriching the scheme leader.

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