Aetna Life Insurance Company (Aetna) has settled an ERISA claim with a woman who claimed that it underpaid or failed to pay claims related to her mental health care and substance abuse disorder treatment. The parties reached a settlement agreement several months after a federal district court granted partial summary judgment in favor of the plan beneficiaries, finding that Aetna had violated the terms of the health plan’s medical necessity criteria.
The judge ruled that Aetna had used inconsistent reimbursement rates for one treatment facility and denied coverage completely for the other facility, which was a transitional program. In doing so, the judge concluded, Aetna violated federal law. The judge dismissed the beneficiaries’ federal mental health parity law claim.
Health plan beneficiaries Alan R. and his daughter, J.R., originally sued Aetna in April 2020 in R. et al. v. Aetna Life Insurance Company et al., case number 3:20-cv-00441, U.S. District Court for the Western District of North Carolina. They claimed that Aetna had abused its discretion under ERISA by denying claims for mental health care for J.R., who had a history of mental health and substance use disorders, at two Texas facilities.
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