Aetna Settles Spinal Surgery Claim Denials: Are You Entitled to $55,000?

If you’ve had spinal surgery claims denied by Aetna, you might be entitled to significant compensation. A recent settlement could provide up to $55,000 for those whose lumbar disc replacement surgeries were wrongly deemed “experimental” and denied coverage. This blog post will explore the details of the settlement, who is eligible, and what steps you can take to determine if you are entitled to compensation.

The Back Story: Aetna’s Spinal Surgery Claim Denials

Aetna Life Insurance Co. has faced numerous lawsuits over its denials of coverage for lumbar artificial disc replacement (L-ADR) surgeries. Plaintiffs in these cases argued that Aetna wrongly categorized the procedure, despite its FDA approval for over a decade, as “experimental and investigational,” thus not medically necessary. This categorization led to widespread denials, leaving many patients to shoulder the financial burden of necessary spinal surgeries.

In one case, plaintiffs Brian Hendricks and Andrew Sagalongos filed a suit against Aetna in 2019, alleging that the insurer’s policy to deny L-ADR surgeries conflicted with their health plans under the Employee Retirement Income Security Act (ERISA).

Aetna’s Class Action Settlement: The $55,000 Deal

Aetna has reached a class-wide settlement that allows patients to receive up to $55,000 for spinal surgeries they claim the insurer wrongly categorized as experimental and not covered. The proposed deal covers at least 381 people whose claims were denied, along with certain other patients who paid out-of-pocket for the surgery or will have the surgery in the future. The total value of the settlement is “difficult to quantify,” but Aetna has denied more than $7.1 million in relevant claims, according to a motion seeking preliminary settlement approval from Judge Andre Birotte Jr.

Key Points of the Settlement:

Compensation: Class members may receive up to $55,000 each.
Eligibility: The deal covers individuals whose claims for lumbar disc replacement surgeries were denied. It also includes those who paid out-of-pocket or are planning to have the surgery.
Scope: The settlement addresses claims that Aetna wrongfully denied coverage by categorizing the surgery as experimental.
Future Coverage: Class members who are current Aetna members will be authorized for a future single-level lumbar disc replacement if their surgeon deems it medically necessary, without review by Aetna.
Past Coverage: Class members who aren’t Aetna members anymore are eligible for reimbursement up to the Individual cap for a future lumbar disc replacement if their current health plan doesn’t have coverage.

Who is Eligible for the Aetna Spinal Surgery Settlement?

To be eligible for this settlement, you generally must meet the following criteria:

Denied Coverage: You must have had a claim for lumbar artificial disc replacement surgery denied by Aetna.
Reason for Denial: The denial must have been based on Aetna’s classification of the surgery as “experimental and investigational.”
Time Frame: The denial must fall within the class period defined by the settlement agreement. (Specific dates may vary, so it’s important to verify with legal counsel or the settlement administrator).
Type of Plan: The settlement typically applies to those covered under Aetna health plans governed by ERISA.

Why Were Spinal Surgery Claims Denied?

Insurance companies, including Aetna, may deny spinal surgery claims for various reasons. Some common reasons include:

Experimental or Investigational: As in the Aetna case, insurers sometimes deny coverage, deeming a procedure as not yet proven or medically necessary.
Lack of Medical Necessity: The insurance company might argue that the surgery is not required to treat the patient’s condition.
Failure to Meet Preauthorization Requirements: Many insurance plans require preauthorization or precertification before undergoing spinal surgery. Failure to obtain this can lead to a denial of coverage.
Policy Exclusions: The specific insurance policy may exclude certain types of spinal surgeries or treatments.
Inadequate Documentation: Insufficient medical records or documentation to support the need for surgery can result in a denial.
Alternative Treatments Available: The insurer might argue that less invasive or conservative treatments should be tried first.

What to Do If Your Claim Was Denied

If you believe your spinal surgery claim was wrongly denied by Aetna, here are steps you can take:

Review Your Denial Letter: Carefully examine the denial letter from Aetna to understand the exact reason for the denial.
Check Your Policy: Review your Aetna insurance policy to understand the coverage terms, exclusions, and requirements for spinal surgery.
Gather Medical Records: Collect all relevant medical records, including doctor’s notes, imaging results, and documentation supporting the medical necessity of the surgery.
Consult with Your Surgeon: Discuss the denial with your surgeon. They may be able to provide additional documentation or support to justify the surgery.
File an Appeal: Follow Aetna’s appeal process, as outlined in your policy. Submit a written appeal with all supporting documentation.
Seek External Review: If your internal appeal is denied, you may have the option to seek an external review from an independent third party.
Contact a Lawyer: If you continue to face difficulties, consider contacting a personal injury or ERISA lawyer experienced in handling denied insurance claims.

Appealing an Aetna Claim Denial: Your Rights and How to Exercise Them

If Aetna denies your claim, you have the right to appeal. Here’s how to navigate the appeals process:

Understand the Process: Aetna is required by law to have an appeals process. Familiarize yourself with the specific steps and deadlines.
Internal Appeal: You have the right to an internal review by Aetna. This involves the insurance company re-evaluating its decision.
External Appeal: If the internal appeal is unsuccessful, you can request an external review by an independent third party, whose decision is final.
Gather Evidence: Collect all relevant documents, including medical records, doctor’s letters, and your insurance policy.
Be Polite and Reasonable: Maintain a respectful tone when communicating with Aetna representatives.
Deadlines: Be aware of the deadlines for filing appeals, typically 180 days from the date of the denial notice.
Expedited Appeals: In urgent situations, you or your doctor can request an expedited appeal for a faster decision.

Why Insurance Companies Deny Claims

Insurance companies may deny claims for various reasons, including:

Lack of Medical Necessity: The insurer determines the procedure isn’t medically necessary.
Experimental Treatment: The treatment is considered experimental or investigational.
Policy Exclusions: The policy doesn’t cover the specific procedure.
Pre-authorization Issues: Failure to obtain required pre-authorization.
Insufficient Documentation: Inadequate medical records to support the claim.

What if You Need Spinal Surgery But Can’t Afford It?

If you require spinal surgery but are concerned about the cost, explore these options:

Negotiate with the Provider: Discuss payment options or discounts with the surgeon and hospital.
Seek Financial Assistance: Look into financial assistance programs or charities that help patients with medical expenses.
Consider a Medical Loan: Explore medical loans or financing options to cover the cost of surgery.
Check for State or Local Programs: Some states or local governments offer programs to assist residents with healthcare costs.

The Importance of Legal Assistance

Navigating denied insurance claims and settlement processes can be complex. An experienced attorney can:

Evaluate Your Case: Assess the merits of your claim and eligibility for the Aetna settlement.
Gather Evidence: Collect and organize necessary medical records and documentation.
Negotiate with Aetna: Represent you in negotiations with Aetna to maximize your compensation.
File a Lawsuit: If necessary, file a lawsuit to protect your rights and pursue your claim in court.

Conclusion: Take Action to Claim Your Entitlement

If you’ve had spinal surgery claim denials from Aetna, don’t lose hope. The recent settlement offers a potential avenue for compensation. Take proactive steps to understand your eligibility and pursue your claim. Contacting a qualified attorney can provide invaluable assistance in navigating this process and ensuring you receive the compensation you deserve.