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Spencer Recovery Centers, Inc. vs. Aetna US Healthcare, CV 01-6684 SVW

The Patient was a 47 year-old female. She presented with a history of escalating alcohol abuse over the preceding 18 months. She had a prior arrest for DUI. She had a history of morning tremors, alleviated by additional alcohol. She also reported experiencing alcohol blackouts. She had last consumed alcohol the day before admission and she reported daily drinking, with binges, consuming up to 1.5 liters of hard liquor. She reported having drunk two fifths of Vodka over the weekend before entering treatment.

The attending physician’s diagnosis, was "Alcohol Dependence". Upon admission, he placed the patient on detoxification status, where she remained for 4 days. After that, she was stepped down to an inpatient rehabilitation level of care for 15 days and then to a partial hospitalization level of care for 13 days, before she was discharged from treatment. While undergoing inpatient residential care, she continued with group and individual therapy, as part of Spencer' alcohol rehabilitation program. The IDT Progress notes document her progress through treatment.

At no time during the course of the patient’s treatment did any physician, acting on behalf of Aetna, ever physically examine or speak to her; and at no time during her treatment did any Aetna representative ever identify or propose any alternative course of treatment to help the patient overcome her problems with alcohol dependency.

Shortly after the patient’s admission, Spencer contacted Aetna to verify the availability of benefits under her health benefit plan. An Aetna representative, advised that inpatient benefits for chemical dependency

treatment were payable at 80% of the "usual, reasonable & customary" (URC) charges, subject to a deductible and a $2,000.00 out of pocket maximum. (i.e. once the patient "co-pay" amount reaches $2,000.00, then Aetna pays 100% of all remaining URC charges).

After the patient was discharged, Spencer submitted a claim for benefits. Approximately a month later, Spencer received a form letter from Aetna, stating that the claim was “pending further review”. Several weeks passed and Spencer called Aetna to inquire as to the status of the claim, only to be told again that the claim was “still in review”. Spencer then received a letter from Aetna requesting a copy of all of the patient’s medical records, which Spencer immediately provided.

Another month passed with still no action taken. Spencer called Aetna again, only to be told once more that the claim was “still in review” and that it would take 90 days from the date of Aetna’s receipt of the medical records, before a decision on the claim could be made. The Aetna representative also said that there was nothing on her computer noting Aetna’s receipt of the requested medical records.

Three weeks later, Spencer called Aetna again, only to be told again that there was no information in Aetna’s computer showing that it ever received the medical records. The Aetna representative instructed Spencer to submit the medical records, yet again, which it immediately did.

Two more months passed before an Aetna representative advised that its review of the medical records was complete and that Aetna was denying the entire claim on grounds of lack of "medical necessity". This denial came eleven months after the services were rendered.

Spencer asked that Aetna generate a letter, specifically stating the reasons for the denial (as required by ERISA). No further response was received from Aetna, thus the claim was “deemed denied” under the regulations in effect at that time. At that point, the file was referred to me.

I sent an administrative appeal letter to Aetna. Aetna ignored it. I had also asked for complete copy of all plan documents describing coverage, as well as all documents that Aetna contended were a part of the administrative record. Aetna ignored the request as well. I also made attempts to informally resolve the matter with Aetna’s legal department. My attempts were unsuccessful, so a lawsuit was filed.

Result: The case was resolved satisfactorily.

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