Aetna, one of the largest insurance providers in the United States, receives billions annually in premium revenue. Despite this significant financial capacity, Aetna, like many other insurance companies, has often been criticized for delaying and denying valid disability claims. If you’re an Aetna policyholder who’s facing issues with your disability claim, this guide will provide you with the necessary information and resources to navigate the claims and appeals process.
In 2018, Hartford Financial Services Group, Inc. (Hartford) entered into a complicated reinsurance and administrative agreement to administer and insurer long-term disability claims of Aetna. The Hartford paid Aetna a cash consideration of $1.45 billion, primarily comprised of a ceding commission paid by Hartford Life & Accident Insurance Company, the primary Group Benefits insurance operating subsidiary of The Hartford. Hartford Life & Accident agreed to reinsure on an indemnity basis Aetna’s book of group life and disability insurance, which had premiums of approximately $2 billion in 2016.
Aetna’s Long-Term Disability (LTD) Policy Provisions
Long-term disability insurance provides beneficiaries with a percentage of their income if they’re unable to work for an extended period due to a covered illness or accidental disability. Aetna’s disability insurance has certain limitations and conditions, including:
- Coverage is limited to certain illnesses or injuries.
- You must miss a specific number of workdays to satisfy the elimination period.
- Disability benefits last for a predetermined period often to age 65.
- Rehabilitation services may be required to facilitate your return to work.
- Other income during your disability period may affect your benefit amount.
- Benefit amounts typically depend on your annual salary, commissions, and other forms of income.
- Often after 24 months, Aetna limits eligibility for long-term monthly disability benefits if your disability is mainly caused by or contributed to by mental health or psychiatric conditions (excluding structural brain damage) or substance abuse.
Dealing with Delays in Aetna Disability Claims
Insurance companies often profit from delaying claims. By holding onto your benefits, they have more money to invest, potentially increasing their profits. If you feel that Aetna is unjustifiably delaying your claims, it’s crucial to contact an experienced disability insurance lawyer to assist you getting the benefits you earned and deserve.
Responding to Aetna Claim Denials
Receiving a claim denial letter from Aetna can be disheartening, but it’s important to remember that there are avenues for recourse. You’re legally entitled to an appeal, allowing your claim to be reviewed again.
In the case of wrongful denial or delay, insurance companies may be acting in bad faithyou’re your coverage is through a private sector employer, then your claim likely falls under the Employee Retirement Income Security Act of 1974 (ERISA). You do not have the same type of remedies available for persons whose claims are outside of ERISA. Top-rated disability insurance lawyers offer free consultations to discuss your situation, helping explain next steps, and guide you through the proces.
Appealing an Aetna Claim Denial
Appeals are requests for a second review of a denied claim. With Aetna, policyholders who have received a claim denial may initiate an appeal. Appealing on your own without fully understanding the process and strategies needed, is like practicing surgery on yourself. It’s not a good path to follow. Often the appeal must be submitted within 180 days of receiving the notice of the denied claim. Meeting these deadlines is crucial, as missing them could affect your ability to sue later if your benefit claim is not reinstated after an appeal.
Exhausting Appeals and The ERISA Framework
If you’ve exhausted all your appeals, you can file an individual complaint or a group ERISA complaint for benefits. The Employee Retirement Income Security Act of 1974 (ERISA) is a federal statute that applies to employee disability insurance benefit plans provided by private employers or labor unions. It protects workers’ rights but often presents a complex system for policyholders, requiring strict compliance with deadlines and submission requirements.
Notable Lawsuits Against Aetna
There have been many lawsuits against Aetna regarding disability insurance claims. One notable case was Ace v. Aetna Life Insurance, 139 F.3d 1241, 1243 (9th Cir. 1998).
In the trial court, the jury ruled for Sherrie Ace on her bad faith claim and awarded her $27,009 for the wrongful denial of disability benefits and $100,000 for emotional distress. It also awarded her $16.5 million in punitive damages. When appealed, the Ninth Circuit sent the case back to the trial court with direction to enter an order denying Aetna’s motion for new trial on punitive damages on condition that Sherrie Ace accept a remittitur of punitive damages to $381,000.
Conclusion
Facing a delay or denial of your Aetna disability claim can be a stressful and challenging experience. Yet understanding the claims and appeals process, your rights, and the available resources can empower you to effectively navigate this process. Remember, you’re not alone – experienced legal professionals are ready to assist and guide you every step of the way.
