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Reopening of Time Period to Allow for Appeals of Partially or Fully Denied Claims and the Reconsideration of Certain Claims

Insurance Superintendent Gregory V. Serio today announced that an agreement has been reached between the Department and Aetna U.S. Healthcare to create an appeals process for claims that had been partially or fully denied during certain time periods. This agreement is a result of an examination that found violations of the Insurance Law for failing to give proper notice of the right to appeal in the Explanation of Benefits Form and problems with the claims systems.

In its recent Report on Examination, the Department found that Aetna U.S. Healthcare had issued to certain policyholders defective Explanation of Benefits forms from July 1, 1994 to July 31, 2001. As a result, Aetna U.S Healthcare has initiated an appeals process for certain policyholders insured under the defective forms. Additionally, Aetna will reconsider certain claims that were partially or fully denied between January 1, 2000 and September 30, 2001 as a result of findings of a serious inadequacies in their claims processing system. Advertisements detailing the appeals processes are now running in newspapers through June in the Plan’s service area. This agreement is indicative of the Department’s creative new approach to health insurance regulation in an effort to make enforcement actions more meaningful for policyholders.

Certain policyholders of Aetna Health Inc., Aetna U.S. Healthcare, Inc., and U.S. Health Insurance Company will reconsider any HMO or QPOS member’s claim which was originally submitted between January 1, 2000 and September 30, 2001 and who has reason to believe that their claim may have been processed incorrectly. Additionally, Aetna will accept appeals from policyholders that received an Explanation of Benefits dated between July 1, 1994 and July 31, 2001 relating to the full or partial denial of a claim who never previously pursued an appeal. In order to be eligible a policyholder must have had a New York Primary Care Physician on the date of the claim. Aetna may be contacted for claims reconsideration at 1-888-305-7649 or for claims appeals at 1-888-305-7649 by September 26, 2002.

Additionally, the Company has filed a remedial action plan for other violations discovered during the examination. The Company has also paid a fine to the Department. The full examination report is available on-line at

Department of Financial Services


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