ComplaintsforAetna Inc.

• Initial Complaint

  09/24/2024

  Complaint Type:

  Product Issues

  Status:

  Resolved

  More info

  My Aetna Medicare Advantage Plan includes a fitness reimbursement benefit of $800 / year. On May 31, 2024 I submitted a fully documented Reimbursement Claim Form to Aetna showing that I had paid $949 for personal training sessions through May 31. My claim was for the $800 benefit included in my plan. Some weeks later I received a check for $231. I contacted Customer Service 4 times about the remaining $569 remaining to be refunded, per my plan: 1) spoke with Bee on 7.1.24 Case No: 136538184 2) spoke with Leo on 8.8.24 3) spoke with Rose on 8.26.24 4) spoke with Eric on 9.11.2024 (Eric made another manual request: Case no *********) On September 23 I received a second check for $231.17. Again, this is not the amount promised and due. The outstanding balance due me is still $338. I believe that Aetna is deliberately trying to avoid reimbursing me. They are looking only at the first of the 6 monthly contractual payments that I made, even though they have a full statement of money paid to ** ******* for personal training through May 31. The trouble and time spent on trying to avail myself of my right is causing me now to seek out a new health insurance provider in the next open enrollment period.

  Business response

  09/26/2024

  **** *** ******* **********
  
  Please see our response to follow-up on complaint # ******** for Mr. Donald Warner that was received by us on September 24, 2024. Our Executive Resolution Team researched the concerns, and we would like to share the results of the review with you.
  
  We have identified the concern our member, *** ****** ******, has is about the way the plan has handled the processing of his fitness reimbursement claim from date of service January 2, 2024, through May 2, 2024. We understand how frustrating this can be and we take our members concerns very seriously.
  
  Upon receiving the concern, we immediately reviewed the member’s account. We confirmed the member is enrolled into an Aetna Medicare Explorer Premier PPO plan with the effective date of January 1, 2024. The plan is currently still active with no anticipated termination date listed. We show the Aetna Medicare Explorer Premier PPO plan includes a direct member reimbursement (DMR) allowance of $800 each year. The benefit states the member can be reimbursed toward fees paid towards personal training.
  
  We show we received a fitness reimbursement form under our internal document control number (***) ************ on June 3, 2024. The request is for training sessions at **** *******. Page 7 of the reimbursement request shows the member paid as follows:
  
  January 2, 2024, paid via **** card $229.
  February 2, 2024, paid via **** card $180.
  March 2, 2024, paid via **** card $180.
  April 2, 2024, paid via **** card $180.
  May 2, 2024, paid via **** card $180.
  
  Total payments made by the member was $949.
  
  We show claim ********* was created incorrectly by claim specialist per *** ************ on June 6, 2024, with a submitted amount of $229, with date of service January 2, 2024, through January 2, 2024. Another claim specialist than incorrectly processed the claim. The plan paid $229, to the member, on June 7, 2024, with check number *******. This check shows as cashed on June 21, 2024.
  
  We show we received another fitness reimbursement form under our internal document control number (***) ************ on June 10, 2024. The request included the same pages as the first documents received and showed the total payments made by the member was $949.
  
  As a result of when the wife called into the plan on July 1, 2024, we show claim ********* was rekeyed incorrectly by claim specialist per *** ************ on July 2, 2024. The new claim was a result of a rekey escalation with a submitted amount of $229 with date of service January 2, 2024, through January 2, 2024. This claim denied on July 5, 2024, as a duplicate to claim *********.
  
  When the members wife called back into the plan on September 11, 2024, the claim was sent back to be reworked. We than show the claim ********* was reworked incorrectly by claim specialist on September 14, 2024. This is when the plan paid an additional $229, plus $2.17 interest, totaling $231.17, to the member, on September 14, 2024, with check number *******. This check shows as cashed on September 25, 2024.
  
  Please know, we send a service improvement coaching to the claims specialist’s supervisor if errors are located during our investigation. After our review of the fitness reimbursement claim(s), and the incorrect processing of the fitness reimbursement claim(s), we did send multiple service improvement coaching’s. We use the service improvements to educate, and retrain, the claim specialists to improve our services to our members.
  
  Based on our findings of the incorrect processing of the member fitness reimbursement claim, we escalated the claim ********* to be reprocessed per the remaining fitness benefit allowance owed to the member. We confirmed on September 26, 2024, the claim was reprocessed to pay the member an additional $342. We ask the member to allow 7-10 business days to receive the check in the mail.

  In addition, we have reviewed all four inbound calls made into the plan about this claim issue. The members wife made all four calls. After listening to the incoming calls, we sent the call from August 26, 2024, for service improvement. The representative advised the claim was still processing. This was incorrect. The representative should have advised the rekeyed claim M08370774 was incorrectly denied on July 5, 2024, as a duplicate claim and sent it back to be reworked correctly. As we want to exceed in our members expectations in both care and in service and found that we did not meet our goal on this call. A supervisor will give the representative feedback on this call to allow for service improvement.
  
  The member will receive a detailed Medicare Resolution Letter within 7-10 business days with this response.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ****** ******’s concerns. We do apologize for the inconvenience this has caused to our member.
  
  Sincerely,
  Marilyn G.
  Analyst, Medicare Executive Resolution

  Customer response

  09/27/2024

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
  
  Sincerely,
  
  ****** ******

• Initial Complaint

  09/23/2024

  Complaint Type:

  Product Issues

  Status:

  Answered

  More info

  I am a Aetna Medicare Advantage Plan member. My plan recently started on 9/1/2024. Since the start of this plan, I have had many problems with this plan for the reasons described below: 1) My plan has $800 fitness allowance. I submitted a reimbursement request for a specific fitness equipment called **** **** ***. The claim #********* was denied. I am appealing this denial because this is a fitness equipment used to strengthen and build muscle in the neck. It is also used by athletes and can be sometimes found in gyms. Please refer to member brochure number ************* (4/24) that states fitness equipment is a covered benefit (see attached). The requested amount to be reimbursed is $652.91. 2) I also submitted a reimbursement request for a vibration exercise plate. The claim #********* was denied. I am appealing this denial because this is a fitness equipment used to burn fat, build muscle, and burn calories. There are various medical studies to support these claims. Please refer to the afformentioned brochure. The requested amount to be reimbursed is $159.13 I spoke to a Aetna supervisor on 9/21/24 to express my concerns (case #*********) and filed a grievance (************) regarding the denial of fitness benefits. I feel that the member brochure is a misadvertisement that fitness equipment are a covered benefit. 3) I had also submitted another grievance with Aetna since their contracted mail order pharmacy *** ******** failed to update my mailing address appropriately and continued to send mail to my old address. The address was previously updated with an Aetna representative and I am still receiving mail addressed to my old address. The supervisor who filed a grievance (************) stated that I should receive a phone call from the resolutions team, but I never received that call. The task ID is ********. I filed a grievance since I feel this is a HIPAA violation for not updating the address appropriately.

  Business response

  09/26/2024

  Dear Mr. ******* *********: 
  
  Please see our response to complaint # #******** for *** *** ******* that was received by us on September 23, 2024.  Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.
  
  Upon receipt of the complaint, we reached out internally to view the member’s concerns. The member’s request for reimbursement for The   **** **** *** *** and  ******* ****** **** ********* ***** Machine were denied because they are not on the approved list of exercise equipment that is reimbursable. We confirmed that the member contacted Aetna about the exercise benefit but there were not calls to inquire about the exact items that the member requested for reimbursement.
  
  The member has a right to appeal.  *********** and *********** are on file and due by November 20, 2024.
  
  The member’s information for the consent to ship was in process prior to the address change on September 08, 2024. The  address is now up to date in that system as well.  This would not be a HIPAA violation unless the person residing in the new address would open the information.
  
  The member did not receive a response from the grievance team because the case had been put into the system but not assigned out.  Grievance has 30 days to respond to the member’s concerns. The member will receive a detailed Medicare Resolution Letter within 7-10 business days.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ************** concerns.  
  
  Sincerely,
  
  Cindi D
  Analyst
  Medicare Executive Resolutions
  
  

  Customer response

  09/26/2024

  
  Complaint: ********
  
  I am rejecting this response because: I would like to request a list of approved items for fitness reimbursement. The handout that I received and attached to this complaint is too vague and does not specifically state what type of fitness equipment is covered. Also, I would need written documentation showing the items are on the list of “ineligible items” since the handout attached is contradictory to Aetna’s decision. 
  
  Sincerely,
  
  *** ********

  Business response

  09/27/2024

  Dear Mr. ******* *********:
  
  Please see our response, to the rejection of our previous response, to your complaint #******** for Mr. *** ********, that was received by us on September 26, 2024. Our Executive Resolution Team took a second look into the member’s concern, and we would like to share the results of the review with you.
  
  We have identified, in this rejection of our previous response, the member is requesting a list of approved items for fitness reimbursement and written documentation showing a list of items that are considered ineligible.
  
  Unfortunately, due to many consumer products available on the market today, there is no way to supply an exact list of approved and ineligible products to our members. This is why the plan supplies the general brochure and encourages our members to contact our customer service line when they question whether an item/product is approved, or not, for the fitness allowance benefit when they do not see the item listed in the plan documents provided to them.
  
  Our customer service representatives utilize a spreadsheet of facts and questions (FAQs), that is updated often, when answering our members questions when they call into the customer service department to inquiry about the fitness allowance benefit and as to whether an item/product may or may not be covered under the benefit. 
  
  It was confirmed during our previous review, that the member did contact our customer service department about the fitness benefit, but there were not calls located where the member inquired about the exact items that the member requested reimbursement for.
  
  As mentioned in our previous response, due to the members fitness reimbursement claim on file denying, the member has the right to appeal. Please know, we encourage our members to utilize the appeal process, as is the only way to overturn the plans decision on a claim. It was confirmed there are two appeals on file that are in progress under appeal case numbers A2426555295 for claim number ********* and *********** for claim number *********. The due date of our appeals department to have a decision, on both appeal cases, is by November 20, 2024. Our appeals department will notify the member directly with the outcome of their decision.
  
  The member will receive a detailed Medicare Resolution Letter within 7-10 business days.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** *** ********’s concerns.
  
  Sincerely,
  
  Marilyn G.
  Analyst, Medicare Executive Resolutions

  Customer response

  09/27/2024

  
  Complaint: ********
  
  I am rejecting this response because: it is deceiving for Aetna to put in the member handout that “fitness equipment” is covered and then later deny me coverage for a fitness equipment such as vibration plate and Iron neck. I consider this misadvertisement since those items are considered fitness equipment. If you are not going to disclose the list of approved fitness equipment to members, this is considered a deceiving marketing practice (bait and switch approach). One of the reasons I signed up for the Aetna Medicare Advantage Plan is the $800 fitness benefit and unfortunately, I have been disappointed with the outcome of the fitness benefit.
  
  Sincerely,
  
  *** ********

• Initial Complaint

  09/18/2024

  Complaint Type:

  Sales and Advertising Issues

  Status:

  Resolved

  More info

  I have repeatedly called and asked to be put on the no mail list for these Medicare advantage plans. I have spoken to supervisors who have promised to take me off the list but I am still receiving. I have NO interest in a Medicare advantage plan at this time and wish to be taken off the mailing list for all marketing.

  Business response

  09/20/2024

  Dear *** ******* *********: 
  
  Please see our response to complaint # ******** for *** ********* ******, which we received on September 18, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.
  
  Upon receipt of the concern, we immediately reviewed *** ******** request. We confirmed that *** ****** is not a member of any Aetna Medicare Advantage plans. We were able to contact *** ****** by email to confirm her mailing address. We have added *** ****** to our internal Do Not Contact (DNC) list. We have also added *** ****** to the external DNC list for marketing materials to non-members. This update will take effect within 24 hours. 
  
  *** ****** was notified of this resolution via email on, September 20, 2024. 
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ******** concerns.
  
  Sincerely,
  Jasmine W.
  Analyst
  Medicare Enterprise Resolution
  
  

  Customer response

  09/20/2024

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
  
  Sincerely,
  
  ********* ******

• Initial Complaint

  09/16/2024

  Complaint Type:

  Product Issues

  Status:

  Answered

  More info

  Subject: Complaint Against Aetna – Failure to Process Reimbursements for Speech Therapy Dear Sir/Madam, I am writing to file a formal complaint against Aetna, my health insurance provider, regarding the difficulty I have experienced in receiving reimbursement for my son’s speech therapy services. Per my insurance agreement, once I met my deductible, I was supposed to receive 60% reimbursement for covered services. However, after receiving my initial reimbursement, every subsequent attempt to receive reimbursement for my son's speech therapy has been met with extreme difficulty. Aetna has repeatedly requested more clear receipts, proper diagnoses, or different forms of bills—documents that I have submitted multiple times. Despite this, I only receive generic email responses that provide explanations of general benefits, with no specific guidance or progress on my claims. I have spent an excessive amount of time contacting Aetna's customer service team, to no avail. In addition to the difficulties with my son’s therapy claims, I also faced issues when attempting to add my wife and newborn child to my insurance plan. As a physician at Envision Healthcare and the head of my department, I pay for top-tier insurance through Aetna and expect better service. However, I am not receiving the return on investment I have paid for. This constant back-and-forth has caused significant stress and financial strain on my family. I respectfully request that the BBB intervene to resolve this issue and ensure that Aetna fulfills its obligations under the insurance agreement. Thank you for your attention to this matter. I look forward to your assistance.

  Business response

  09/23/2024

  Dear ******* *********:

  Please see our response to complaint #******** for Andrew Letayf that was received by us on September 16, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.
  
  Upon receipt of the complaint, we immediately reached out internally to further research the member’s concerns. We confirmed that Aetna does not manage the eligibility for this plan sponsor. All eligibility is fed through their vendor BusinessSolver and sent twice a week to us on a file feed. Please know, we have forwarded the member’s concerns over to the eligibility vendor for review. In addition, we reviewed *** *******’s son’s claim history and found that the diagnosis codes were missing on some of the submissions. To avoid further error, the member must ensure the diagnosis codes are listed on his claim submissions. Please know, there were four claims pending diagnosis information. However, we were able to have those claims reprocessed by using the codes from previous claims. This is also something that our representatives could have done when *** ****** called in. Therefore, feedback was provided to the representatives involved. Furthermore, we identified additional claims that were processed incorrectly, and reprocessed those according to the member’s in network plan benefits. The member should receive an updated explanation of benefits (EOB) within 7-10 business days. Currently, the member’s son does not have any outstanding speech therapy claims. Should *** ****** have any questions regarding the reprocessed claims, he may contact Member Services (reference case number *************) by dialing the phone number on the back of his member identification card.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ******’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *******************************.
  
  Sincerely,
  
  Shay G.
  Analyst, Executive Resolution
  Executive Resolution Team

• Initial Complaint

  09/13/2024

  Complaint Type:

  Billing Issues

  Status:

  Resolved

  More info

  I had a critical illness, Osteomyelitis, and am covered by Aetna supplemental for $7,500. I have submitted the **** but unfortunately the hospital put the incorrect codes in, and since Aetna paid the hospital for the incorrect codes, the hospital is unable to make changes to the codes. Aetna Supplemental denied my claim without contacting me to request more documentation. I've had to call and email them several times with additional hospital records and doctors signed statements that properly point out my diagnosis is osteomyelitis. I've asked them to contact me if any further documentation is required and also asked for appropriate forms that I can have my doctors fill out. They just keep denying it like they are purposefully trying to get out of paying it without even contacting me. This last time, they appropriately set up a new claim with the critical illness and $7,500 payout showing, but then I got an email saying it was settled. I went on their website, and they changed to to hospital indemnity, and denied it. Again, no contact with me whatsoever. This company seems like a scam purposefully denying people until they give up.

  Business response

  09/16/2024

  Dear ******* *********:
  

  Please see our response to complaint #******** for ***** ******* that was received by us on September 13, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.
  

  Upon receipt of your request, we immediately reached out internally to further research the concerns. After further review it was determined that the reason for the denials was that we did not have any documents to support the Osteomyelitis diagnosis. Since the member does have Aetna medical, we were able to locate a claim in the major medical file that had the diagnosis for this condition. Based on that claim we can now release the benefits. The claim was reprocessed paying a benefit of $7,500 to the member’s direct deposit. However, due to the amount it triggered the file be reviewed by auditing. The claim is now being reviewed as HASTE today. Which means the benefits will be released tomorrow, member should see funds in her bank account by mid-week.
  

  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ********s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *******************************.
  

  Sincerely,
  ShaCarra B.
  Executive Analyst, Executive Resolution Team

  Customer response

  09/17/2024

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.

  They finally paid out thanks to BBB.  It's ridiculous it had to come to this.  I even asked to be transferred to the executive resolution branch and was told it does not exist, but the replies in here are from that exact team.  Aetna's staff needs better training, unless of course they are being trained to deny, deny, deny and are purposefully acting like a fraudulent business.  

  Thank you BBB!

  
  Sincerely,
  
  ***** *******

• Initial Complaint

  09/13/2024

  Complaint Type:

  Order Issues

  Status:

  Resolved

  More info

  I am a long term ********** ** ******* ***I employee working for the Air Force. For the past 29 years, I have been paying into the Aetna healthcare through my employer without requiring any health care. 6 months ago, I was diagnosed with a rare, but treatable blood cancer and began treatments. My hospital is in the Aetna network, sent up for direct bill pay, and treatments began. Aetna has paid their 80%, but my 20% out of pocket is not being credited towards my out of pocket expenses. I am averaging $8500.00 monthly towards my treatments, and currently over $30,000 when my yearly expenses should not exceed $5000.00 according to my plan. My hospital will not deal directly with Aetna citing issues they have had with them in the past, so it is on me to balance working full time, chemotherapy, and deal with sleepless nights on the phone with them. I have exhausted a line of credit, cashed in my 401k, and am currently being forced to retire early at a significant monetary loss and move overseas in a effort to be able to seek affordable healthcare. Apologies from Aetna does not slow the hemorrhage of money being lost every month. I receive the same questions and excuses from Aetna on a weekly basis, and several "It will be fixed by (insert date)". The last was 6 September, only to mail and be told "Ten more days" four days ago. Nearly every claim has requested the information that was uploaded when I created it. I have to call the help desk, have them review what was uploaded, they confirm everything is there, and resubmit. 2 weeks later, it is returned requesting the files once again. I've given them the benefit of the doubt for far too long, and two of my coworkers have also had the same exact issue of dealing with their weaponized incompetence.

  Business response

  09/20/2024

  Dear ******* *********:
  
  Please see our response to complaint #******** for ****** ******* that was received by us on September 13, 2024.  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.
  
  Upon receipt of the member’s concerns we immediately reached out to investigate. We found an issue where member responsibility was continuing to be applied incorrectly. We have resolved the issue and corrected the member’s claims. Additional payment will be sent along with updated statements. We have taken steps to ensure the future claims are handled correctly.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. Kempton’s concerns.  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *****************.
  
  Sincerely,
  
  William B.
  Analyst, Executive Resolution
  Executive Resolution Team

  Customer response

  09/23/2024

  To whom it may concern,

  Hello..
  
  My out of pocket maximum has indeed been reached, and I appreciate the assistance. If Aetna is working with an overseas hospital, and that hospital does not, or will not file any paperwork on the behalf of their patients, sadly, it is up to the member to do so.. and it seems that "Member responsibility was continuing to be applied incorrectly" means my attempts at filing said paperwork was done in error. Yet, after reaching out time and time again, answers to what was in error were not answered, and continue to not be answered. I wish to have all information correct, but guidance is required to do so.  I have responded to several individuals, and lastly to "Miguel" who is the "Plan sponsor liaison for the ********** ** ******* health benefit plan" at Aetna, since his email reached me just after contacting the BBB as to what is needed to provide clean claims in the future, and when I could expect reimbursement for my overpayments, but have not received an answer as of 20 Sep 24. I am looking forward to understanding how my member responsibilities were incorrectly applied, and answers to my questions on what is needed to avoid any future issues. I will share with my coworkers who have also had multitudes of problems, so we are all on the same sheet of music. 

  Business response

  09/27/2024

  Dear ******* *********:
  

  Please see our response to complaint #******** for ****** ******* that was received by us on September 23, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.
  

  Upon receipt of your request, we immediately reached out internally to further research the concerns. After further review it was determined that the system was inadvertently continuing to apply a member responsibility. This was due to the member and provider submissions being out of synch. The root cause has been identified and worked through the member file to confirm all claim submissions from the member and the providers, it will now apply correctly to the accumulators. We have also placed a special handling flag on the members file and have assigned a dedicated processor who will ensure all transactions are applied appropriately. The issue has been fixed and the member will be receiving $17,385.11 that he is owed. The member should allow 7-14 days for the reimbursement to be received.
  

  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ********* concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *******************************.
  

  Sincerely,
  ShaCarra B.
  Executive Analyst, Executive Resolution Team

  Customer response

  09/28/2024

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
  
  Sincerely,
  
  ****** *******

• Initial Complaint

  09/13/2024

  Complaint Type:

  Order Issues

  Status:

  Resolved

  More info

  I am writing to request authorization to fill my 90-day prescription for ******** at a pharmacy of my choice, as *** ******** does not currently carry this medication. ******** is essential for managing my type 2 diabetes and has significantly improved my health, enabling me to achieve and maintain an A1C level under 7. However, ******** frequently appears on the *** drug shortage list. As a result, I have had to use MedFinder services, incurring costs of up to $200 to locate this medication. In light of these challenges and to avoid costly emergency room visits and uncontrolled health issues, my doctor prescribed a 90-day supply of ********. Given *** ********** inability to fulfill this prescription, I request your approval to obtain it from a local pharmacy that does have it in stock.

  Business response

  09/17/2024

  **** ******* *********:
  
  Please see our response to complaint #******** for ******* ****** that was received by us on September 13, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.
  
  Upon receipt of the complaint, we immediately reached out internally to further research the member’s concerns. Please know, the member’s request has been approved and entered in her account until December 31, 2024. Should the member have any questions or if she wishes to request an extension, she may contact customer care at ###-###-#### for further review.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. ******** concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *******************************.
  
  Sincerely,
  
  Shay G.
  Analyst, Executive Resolution
  Executive Resolution Team
  

  Customer response

  09/17/2024

  
  Better Business Bureau:
  
  I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.
  
  Sincerely,
  
  ******* ******

• Initial Complaint

  09/10/2024

  Complaint Type:

  Order Issues

  Status:

  Answered

  More info

  7/30/2024 I paid my Aetna health insurance premium of $118.89. On 8/12/2024 one of Aetna's systems somehow terminated my insurance. After several hours and phone calls to Marketplace, an Aetna tier 2 agent reached out to the enrollment manager, who reinstated my insurance as active. The reason for the cancellation was an error in one of Aetna's systems, which triggered "down stream systems" to terminate my coverage as well. My insurance was made active again. 8/28/2024 I again paid my premium of $118.89 and have learned on 9/10/2024 that my insurance has been terminated again. Aetna needs to investigate why this keeps happening and resolve the issue so this does not keep happening to me. I spend countless hours on the phone with various concierges and agents, doing other people's jobs without getting paid for it.

  Business response

  09/20/2024

  **** *** ******* **********
  
  Please see our response to complaint #******** for ******** ***** that was received by us on September 10, 2024. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.
  
  Upon receipt of your request, we immediately reached out internally to have *** *****’ concerns reviewed. Based on the review it has been confirmed that *** *****’ policy was reinstated on September 10, 2024. Our enrollment department confirmed that a manual reprocessing of financial changes is what caused the spans of cancellations. A successful outreach was made to the member to inform of the account status, reason for the accounting terminating, and steps Aetna has taken to prevent this from happening again.   
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** *****’ concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *****************.
  
  Sincerely,
  
  Marshell H.
  Analyst, Executive Resolution
  Executive Resolution Team

• Initial Complaint

  09/09/2024

  Complaint Type:

  Billing Issues

  Status:

  Answered

  More info

  My company switched our health insurance provider mid-plan-year, and we were instructed to submit deductible credit letters to the new provider, Aetna, so that the deductible spending we had accrued through the first half of the year would be reflected in the new plan. I originally submitted this letter to Aetna on July 7, 2024, and my in-network deductible credit was applied, however the out-of-network deductible credit (documented on the same document) was not applied. I called Aetna about this issue on August 6, 2024 and the agent recognized the error and re-submitted it for processing. I was told it should be reflected in 7-10 business days but it was not. I resubmitted the document digitally on August 19 after the out-of-network credit was not applied and again waited 7-10 business days but the credit was not applied. I called customer service again on September 5, 2024 (call reference number 151811016) and was told that my request was being expedited and it would be processed in 1-3 business days, but again this did not happen. I just called customer service again today on Septeber 9, 2024 (call reference number *********) and was told they were resubmitting my document it would be another 7-10 business days before the credit could be applied. In the meantime I have spent over $2,000 out of pocket on medical costs which should have been covered if the deductible had been applied. I have called customer service a total of 3 times so far about this issue (in addition to submitting the credit letter twice digitally) and have no faith that they will resolve it as each time I have been told that it will be handled but it has not yet been resolved.

  Business response

  09/18/2024

  **** *** ******* *********:
  
  Please see our response to complaint #******** for ******* ******* that was received by us on September 09, 2024. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.
  
  Upon receipt of your request, we immediately reached out internally to have Mr. *******’s concerns reviewed. Based on the review it has been confirmed that the out of network deductible credit of $5,000.00 and the out of network out of pocket credit of $5,624.17 has been updated towards the family’s out of network deductible and out of pocket maximum. The family has exceeded their out of network deductible on the plan. The claims department has reprocessed four of Mr. *******'s medical claims that were applied towards the deductible. Their are two claims for Daisy, which applied towards the deductible that will be reprocessed. This will bring the family back to the deductible limit on the plan. It can take upto 10 business days to have the claim reprocessed. Those payments will be issued to the member.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. *******’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *****************.
  
  Sincerely,
  
  Marshell H.
  Analyst, Executive Resolution
  Executive Resolution Team

• Initial Complaint

  09/09/2024

  Complaint Type:

  Order Issues

  Status:

  Answered

  More info

  I retired after working for my employer for 27 years in 2014. I retained my company’s insurance with my wife being on the plan ever since retirement. Aetna insurance dropped my wife’s coverage for no reason, or no explanation. My employer has contacted Aetna insurance to inform them that my wife has always been on my policy since July, 2009. Aetna insurance has paid claims, then has taken them back without proper cause. I need help with having the responsible person with Aetna insurance company to contact either my employer or myself to have these charges paid. These healthcare companies are threatening to turn me over to collections over these bills

  Business response

  09/18/2024

  Dear ******* *********:
  
  Please see our response to complaint #******** for ***** ******* that was received by us on September 9, 2024. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.
  
  Upon receipt of the complaint, we immediately reached out internally to further research the concerns. We confirmed that the Mr. *******’s employer terminated from Aetna on January 1, 2024, and moved to a new carrier. Therefore, Mr. ******* and his dependent should have also had a termination date of January 1, 2024. Unfortunately, there was an error made by the third-party vendor when they forwarded Aetna the employer’s eligibility file. This error caused Mr. *******’s spouse to be removed from the plan. Please know, the system has been updated and all impacted claims have been reprocessed. We are unable to provide specific claim information without having a signed authorization form on file from Mr. *******’s spouse. However, if Mr. ******* would like more information, he may contact Member Services at ###-###-####.
  
  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. *******’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *******************************.
  
  Sincerely,
  
  Shay G.
  Analyst, Executive Resolution
  Executive Resolution Team
  

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