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Insurer slapped by CA regulators for emergency room claim denials

On Behalf of | Sep 14, 2020 | Bad Faith Insurance Claim Denial

Let’s just say that national health insurer AETNA has a flatly unusual view of what the term “reasonable” means.

In fact, the coverage provider – one of America’s largest, with a robust operating presence in states spanning the country – is distinctly at odds with what that standard implies in the minds of health care regulators.

And it is precisely that disconnect which has drawn both exacting scrutiny and ire from California authorities. In fact, the state’s Department of Managed Health Care recently slapped Aetna with a $500,000 fine for conduct surrounding patient care that regulators say led to patently unreasonable claim denials for legions of policyholders.

California’s law relevant to patient care in an emergency context is clear. Health providers must cover ER care, except in cases where insured parties did not need it and “reasonably should have known” that such was the case.

There can of course be some divergence in opinion regarding the standard’s parameters, and it might understandably be expected that an insurer sometimes objects to paying for emergency care.

But in virtually every case? DMHC analysis of ER-linked claims over a meaningful measuring period led to the startling conclusion that 93% of Aetna’s denied emergency claims should have been approved under California’s enumerated standards.

Aetna is apparently a slow learner. Reportedly, its misalignment with state standards has been on regulator radar in multiple instances going back several years. The insurer was fined in both 2015 and 2016 for similar emergency service denials.