Complaint 4 of 5 in “In Network / Out of Network Issues”

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  • Insurance Carrier: Aetna/SRC
  • State: ME

Consumer Complaint:

I was employed with Temp Force Service on or about Aug. 2008. I obtained insurance with Aetna/SRC approximately a week later. On November 7th, I was laid off from my job with TempForce, but still continued to pay my insurance premiums which were $49.70 paid every two weeks. In Nov., I was diagnosed with a lemon sized fibroid tumor that had to be removed. I reasearched a participating provider and scheduled the surgery for that December(the 10). I received one bill from St.Elizabeths Medical Center for $1.449.04. I called and explained that I was on UI and only receiving $182.00 a week. I was going to have trouble paying the bill. They refered me to The Mother Bernadine Community Service and they were able to pick up the bill in full. Subsequently, I received a bill for $5758.67 from Little Falls Hospital and when I called Aetna, they had informed me that I had exhausted all of my benefits. I also received a bill for $920.00 for the anesthesiologist andAetna did not touch this one. I called and asked about their (LFH) Comm.Program and filled out the forms, but was turned down because they said I did not go to a participating provider. I also got a letter saying they had dropped me.

Insurance Expert Answer:

We don't know what to say, other than to wish you a speedy and full recovery. The policies provided through temp agencies are typically low end, bottom of the barrel coverages, and strictly construed -- and there is no one at the employer who you might enlist to go to bat for you.

As a private employer-sponsored health plan, they are covered by a federal law known as ERISA, which means that any appeals from claim denials must be made on a timely basis, through the insurance company's appeals mechanism, and appeal rights are very limited.

If you go out of network, and the policy permits them to deny coverage, they will deny the claim to the extent the policy pemits them to do so, even if you'd and they'd have benefitted from what you did to save money. But don't take their word for anything and don't deal with the clerks at the call center.

Read the policy carefully, and if you think the policy wording provides the doctor should be covered, send a polite letter to the VP for Claims and demonstrate why the policy wording provides coverage.

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