Division of Insurance Comments on Aetna’s California Case

DENVER, Colorado, Feb. 12 -- The Colorado Department of Regulatory Agencies issued the following news release:

In response to information arising from a lawsuit in California against the health insurance carrier Aetna, Interim Insurance Commissioner Michael Conway is emphasizing that the Division of Insurance (DOI) will work to ensure that Colorado consumers' appeal rights are offered in compliance with Colorado law.

"We take this information seriously," said Commissioner Conway. "This is a story out of California, but Aetna is a national company with a footprint in many states, including Colorado. Our office will be contacting Aetna to inquire further."

The case involves an appeal by one of Aetna's insureds who was denied coverage for a medical procedure. According to reports, during a deposition for the case, the company's former medical director for Southern California stated that he did not look at patients' records when deciding to approve or deny coverage.

Colorado law states that in appeals to an insurance company, the physician conducting the review must be familiar with the standards of care for Colorado, must evaluate the appeal, must consult with other specialists if the case is outside of the physician's area of expertise, and must sign a written determination. If the appeal involves what was a request for a pre-authorization of a service, the physician evaluating the appeal must be different than the one who reviewed the initial pre-authorization request.

When consumers contact the DOI regarding health insurance appeals, part of the Department of Regulatory Agencies (DORA), the Division helps them understand their appeal rights and ensures that the insurance companies follow the steps required by Colorado law.

"It's an important part of consumer protection," said Dayle Axman, director of the Division's health insurance section of consumer services. "We want to make sure that consumers understand and take advantage of their appeal rights."

For more information about appeal rights, the Division offers the brochure "When your health insurance carrier says 'No' - Your rights regarding pre-authorization and appeal procedures" on its website.

If you have questions or concerns about your appeal processes and rights, contact the Division of Insurance - 303-894-7490 / 800-930-3745 (outside the Denver metro area) DORA_Insurance@state.co.us / AskDORA.colorado.gov (and click on the "Health Insurance" tab).