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Press Release

December 12, 2018

Contact: Richard Loconte, 212-709-1691

DFS FINES TWO NEW YORK LICENSED INSURERS MORE THAN $2.5 MILLION FOR VIOLATIONS OF INSURANCE LAW

Aetna Insurance Company to Pay Fine of $1.95 Million for Missing Deadlines to Make Pre-Authorizations, Acknowledge and Respond to Member Complaints and Acknowledge Receipt of Members’ Grievances, Among Other Violations

Oscar Insurance Company to Pay Fine of $576,950 for Failing to Adhere to Deadlines for Utilization Reviews, Failing to Include Explanations of Adverse Determination Notices and Failing to Include Forfeiture Language in Benefit Statements

Financial Services Superintendent Maria T. Vullo today announced that the Department of Financial Services (DFS) has signed consent orders with two health insurers totaling more than $2.5 million for violations of New York Insurance Law.  Aetna Health Inc., Aetna Health Insurance Company of New York and Aetna Life Insurance Company will pay a civil penalty of $1,950,000 for violations including the failure to make prospective determinations, including pre-authorizations, and failure to acknowledge and respond to members’ complaints within required timeframes.  Oscar Insurance Corp. will pay a civil penalty of $576,950 for violations including the failure to adhere to deadlines for utilization reviews and failure to include detailed explanations of adverse determination notices.

“Consumers have the right to know that their insurers will promptly respond to their needs related to their health care on a timely basis, as required by New York Insurance Law,” said Superintendent Vullo.  “These consent orders demonstrate that DFS will continue to protect New Yorkers and ensure that all insurers obey the law.”

Aetna

A DFS market conduct examination found that from January 1, 2012 through December 31, 2015, Aetna failed to do the following, among other violations:

  • Make prospective determinations, including pre-authorizations, within three business days of receipt of all necessary information;
  • Acknowledge and respond to members; complaints within the required time frames
  • Acknowledge receipt of a member’s grievance within 15 days;
  • Make a grievance determination within 30 days;
  • Send initial adverse determination letters to the insured and providers within 30 days;
  • Make an appeal determination within 60 days of all necessary information to conduct an appeal.

The insurer also failed to provide the insured, the insured’s designee or health care provider in writing of the appeal determination within two business days; in appropriately applied cost sharing to certain preventive care services; and inappropriately denied claims related to certain preventive care services.

Under the consent order announced today, Aetna will make the following corrections among others:

  • Review and revise, where necessary, all procedures related to utilization review, appeals, grievances and complaints to ensure that timely determinations and notifications are given to insureds, providers, and other recipients;
  • Review and revise all adverse determination letters for external appeal and timeframe information in compliance with New York Insurance Law and federal statutes;
  • Monitor all vendors who may perform the services listed above.

Aetna also will reprocess all preventive care claims where cost sharing was inappropriately applied and make overdue payments, including interest; and reprocess all claims that were inappropriately denied, and make overdue payments, including interest.

Oscar Insurance Company

A DFS market conduct examination found that from January 12, 2013 through December 31, 2015, Oscar Insurance Company violated insurance law as follows:

  • Failing to make a determination for prospective utilization reviews within three business days;
  • Failing to make a determination for concurrent utilization reviews within one business day; 
  • Failing to include an accurate and detailed explanation of the clinical rationale for the denials in the adverse determination notices; and
  • Failing to include forfeiture language in the explanation of benefit statements.

Under the consent order announced today, Oscar Insurance will take action to correct the violations, including but not limited to:

  • Revising explanation of benefit statements to include the appropriate forfeiture language;
  • Revising adverse determination notices to include a detailed explanation of the clinical rationale for denials; and
  • Reviewing and revising all procedures, if necessary, related to utilization review in order that timely determinations are made.

A copy of the Aetna consent order can be found here.

A copy of the Oscar Insurance Company consent order can be found here.

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