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Patients, Doctors Sue Aetna For Alleged Coverage Denials

Lawsuit alleges retaliatory action from largest US insurer
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LOS ANGELES (CBS) — Thousands of doctors and patients in Southern California and throughout the state filed a lawsuit Tuesday against one of the nation’s largest health insurers.

KNX 1070’s Pete Demetriou reports the lawsuit alleges alleges that Aetna regularly denies payment to patients who use out-of-network doctors or medical facilities, despite assuring patients they are covered for both in-network and out-of-network services.

Aetna denied any wrongdoing, insisting the company only takes action against doctors who try to drive up patient costs by referring them to out-of-network facilities owned by the doctors themselves.

The Los Angeles Superior Court lawsuit also claims the insurer cancels or threatens to cancel contracts of doctors who refer patients to out-of-network surgery centers.

Aetna continues “its illegal practice of restricting its members’ rights to use out-of-network providers, has continued to threaten physicians who refer to out-of-network facilities, and has refused to pay for out-of-network benefits for which its members expressly contracted,” according to the lawsuit.

Dr. Andrew Brooks — among multiple plaintiffs in the suit including the Los Angeles County Medical Association (LACMA) and California Medical Association (CMA) — said both patients and physicians are targeted by Aetna’s strong-arm tactics.

“They end up bullying the physician, bullying the patients through letters being sent to both the physicians as well as the patients that makes the patient believe they’re going to have all sorts of economic penalties,” said Brooks.

Company officials said it was “troubling that the California Medical Association and other county medical associations would support this type of egregious behavior from physicians” and that the insurer’s actions “protect our members from the small number of doctors who are putting profits ahead of patient care.”

According to the Aetna statement, the company contends it has sued some of the doctors and surgery centers named in the complaint “for their egregious billing practices” in February.

“We will continue to pursue medical providers whose charges are so grossly out of line,” according to the company.

(©2012 CBS Local Media, a division of CBS Radio Inc. All Rights Reserved. This material may not be published, broadcast, rewritten, or redistributed. Wire services contributed to this report.)

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