January 18, 2023

Have You Been Paying for Aetna Insurance but Had Your Claim Denied?

Health insurance companies are in the business of making money, not paying out huge claims. When a client’s claim is denied and they don’t fight back, the insurance company wins because it doesn’t have to pay the claim.

Or, perhaps the insurance company gives you the run-around about the status of your claim or drags its feet in paying it. Unfortunately, this happens more often than many people think. If you’ve been on the receiving end of a legitimate claim that was denied, you know how unscrupulous insurance companies can be.

We Can Help with Aetna Claim Reconsideration

When you pay your health insurance premiums to a company like Aetna, you do so in good faith that the insurance company will pay a claim you submit when you need it. But all too often, insurance companies deny medically necessary claims to those who need them most.

Don’t suffer if you’ve been a victim of bad-faith insurance. If you’re wondering, “How do I fight an Aetna denial of my claim?” we can help.

Trust the legal team at Doug Terry Law to help you pursue a lawsuit for an Aetna claim denial. Contact us today at (405) 293-3541 for a free consultation about your case.

Reasons for an Aetna Claim Delay or Denial

What Does a Denied Claim Mean for Aetna?

What does a denied claim mean for Aetna? Your health insurance policy is a contract between you and Aetna. You pay your monthly premiums in full and on time. In return, they cover the medical treatment you need when you need it.

Nonetheless, insurance companies like Aetna may deny a claim. Sometimes it’s for a legitimate reason, but sometimes it’s not — and understanding the difference can help you understand what a denied claim means for Aetna policyholders.

If you’ve had a health treatment or disability claim denied by Aetna, it could be because:

  • The procedure is considered cosmetic (not medically necessary)
  • Your doctor is out of network or doesn’t participate in the plan
  • Your plan doesn’t cover your medical condition
  • The treatment is considered experimental, or the procedure is investigational
  • You misinterpreted something in the initial application for coverage
  • You didn’t disclose a pre-existing condition on your application
  • There were problems with the paperwork or application
  • The medical exams conducted were deemed insufficient or inadequate.

These are fairly common reasons for a denial. However, if none of these reasons apply, you may be the victim of a bad-faith insurance company.

Why Choose Doug Terry Law?

Even if you had your initial claim denied, you might still be able to get the coverage you paid for and deserve. Sometimes, appealing a claim can be difficult, and insurance companies use language in their policies that is deliberately confusing and complex.

An attorney with experience dealing with bad faith insurance companies — one who knows how to appeal a claim with Aetna — can help.

Contact Doug Terry Law today at (405) 293-3541 to discuss your denied claim. As a policyholder, you have the right to appeal your claim and to hire counsel to help you appeal your claim.

After a claim denial, you might have questions. Here are a few of the most common questions we hear:

How do I fight an Aetna denial of my claim?

The first step in appealing your denied Aetna claim is to ask the company for a review. This is called an appeal. The company provides two ways for policyholders to submit a review:

  • Call Member Services using the phone number on your member ID card.
  • Submit a review request in writing. You can download the form and mail it.

Policyholders may either file the claim reconsideration on their own or designate a representative (such as a lawyer) to appeal the claim. You have 180 days from the date on the notice of a denied claim to appeal it unless your plan explicitly states that you have a longer time to appeal.

I want to know how to appeal a claim with Aetna. What does my request need?

Your Aetna claim appeal request should include:

  • The policy group name (usually your employer or the plan’s sponsor)
  • Your name and member ID number
  • Any documents, medical records, or other information that substantiates your claim and needs to be considered, including lab work.

The length of time it takes for Aetna to respond to your appeal can vary and depends in part on the state laws where you live, whether the appeal is urgent, and whether your plan offers one level of appeals or two.

It’s important to provide all necessary documentation when appealing, as you may only have one chance. Failure to do so could result in your benefits being voided.

What are my options for an Aetna claim reconsideration?

If you appeal, either once or twice, as per your plan, and Aetna still denies the claim, then you have the right to request an external review using an independent physician.

Aetna allows members to request an external review if the claim was based on an investigational or experimental procedure or if Aetna denied it because it wasn’t deemed medically necessary.

It’s important to note that requesting an external review isn’t necessary before pursuing legal action. If you’re considering filing a lawsuit for a bad faith insurance claim, follow your lawyer’s advice about seeking an external review. It might be better to take your case straight before a judge.

How do I fight an Aetna denial of my claim?

In the U.S., the insurance company — not your doctor — determines whether your healthcare procedures are medically necessary. When your healthcare provider submits a pre-approval or a claim, the insurance company determines if it will be covered.

Your doctor may recommend alternative treatments for your condition, but your plan may not cover those, and in fact, the insurance company can deny the benefits if they see the procedure as anything other than a life-saving option.

If this happens, you can file a lawsuit for breach of contract and wrongful denial of coverage. Bad faith insurance includes denying claims when the company doesn’t consider medical opinions, research, or perform an investigation.

Give our attorneys a call today to discuss your case for a bad faith insurance claim against Aetna.

Your Damages from a Bad Faith Insurance Lawsuit Against Aetna

Filing a Lawsuit for Denied Medically Necessary Treatment

If you can’t get pre-approval from Aetna for the medical procedure or treatment your physician recommends, you may have to pay out of pocket. In the U.S., excessive medical bills can financially ruin a family.

Suppose that you cannot afford to pay out of pocket and wait for the claim to be approved before starting treatment. The longer you delay, the worse your condition could get, resulting in higher medical costs down the road.

In the worst cases, victims of bad faith insurance may not be eligible for treatment if their condition progresses to an untreatable point. The result may even be fatal if your health insurance claims are repeatedly denied.

If your Aetna claim is denied in bad faith, you have the right to hire an attorney and file a bad faith insurance lawsuit. You can claim damages to help you recoup the costs of the medical bills you already paid and the additional treatment you need.

Your compensation also includes other financial losses, such as missed wages because you were too sick to work. You may also file for loss of future earnings if you lost your job because of excessive absenteeism (due to your condition) or if the delay in treatment prevents you from being able to work.

Many people experience significant emotional trauma and mental stress when fighting with an insurance company to approve their claims. This, plus the overall stress and trauma of dealing with the medical condition, is considered pain and suffering, which can be part of your damages.

Lawsuits have both economic damages (your quantifiable financial losses) and non-economic losses (pain and suffering). Your bad faith insurance attorney will typically ask for both.

Suppose the ongoing insurance battle results in the untimely death of your loved one. In that case, your lawyer may file a wrongful death suit against Aetna, including economic and non-economic damages, burial expenses, and other considerations, like loss of companionship and loss of consortium.

Do You Need Help Filing a Lawsuit Against Aetna for a Denied Insurance Claim?

If you’ve had a claim denied by Aetna and you believe there was no justification, you may have grounds for a bad faith insurance claim denial lawsuit. We can help. Contact Doug Terry Law at (405) 293-3541 for a free consultation about your case. We aren’t afraid to take on unscrupulous insurance companies, and we will work for you.

Attorney Doug Terry

Attorney Doug TerryAfter 25 years practicing in a larger firm, Doug chose to open his own practice in Oklahoma City. He brings his wealth of knowledge and his skills as a litigator to bear for his clients in matters of insurance bad faith, personal injury cases and class actions. He won $200 million and $25 million verdicts for clients in cases in which an insurer denied a health insurance claim. Doug has the distinction of being awarded a Martindale-Hubbell “AV Preeminent” rating from his peers in the legal community. He has also been selected as an Oklahoma Super Lawyer. [Attorney Bio]