PID finds violations by Aetna Insurance

HARRISBURG — The Pennsylvania Insurance Department (PID) has announced the results of a market conduct exam on Aetna that found several violations by the health insurance company that negatively impacted policyholders. As a result, the company must pay a $550,000 penalty, fix its practices, and repay affected Pennsylvanians. PID's market conduct exams are one of the most impactful ways the Shapiro Administration prioritizes consumer protection. These exams hold insurance companies accountable and ensure Pennsylvania families receive the coverage they are promised.

"A few years ago, Governor Shapiro tasked PID with making mental health parity a true reality for Pennsylvanians," said Pennsylvania Insurance Commissioner Michael Humphreys. "Today's announcement is another giant step toward that ultimate goal and represents just one of the many ways PID protects consumers. Our front-end compliance reviews and back-end enforcement is among the most robust in the country, and we will continue to enforce Pennsylvania laws and regulations to the fullest extent of our statutory authority."

The Aetna exam covers the period from October 1, 2021, through December 31, 2022. A Consent Order was signed in January 2026. The full report can be found on PID's website.

PID's exam found:

Incomplete claims files, especially for Autism Spectrum Disorder (ASD) services;

Delays in approving or denying claims and failure to explain those delays;

Improper claim denials due to poor internal communication about prior approvals and other insurance coverage;

Failure to clearly explain member cost-sharing for ASD services; and

Violations of mental health parity laws, including incorrect or incomplete analysis and application of benefit limits.

PID also found broader "universe" violations. These included flawed methods for reviewing mental health parity compliance and failure to clearly list cost-sharing for ASD services in most plans. The company also confirmed it was not sending required claim delay letters during the exam period.

Under the Consent Order, Aetna must:

Reprocess claims that were handled incorrectly and pay members what they are owed, with interest;

Improve internal systems to make sure claims are processed correctly and on time;

Clearly explain cost-sharing in benefit documents;

Fix denial letters so they clearly explain why services were denied, especially for Applied Behavior Analysis services for ASD; and

Reprocess claims that did not meet mental health parity requirements and provide proof of repayment to PID.

Aetna must complete most of these corrective actions within 12 months, with regular reports to PID.

Pennsylvanians with questions about their insurance or who wish to file a complaint can visit pa.gov/consumer or call 1-866-PA-COMPLAINT (1-866-722-6675).

Consumer Protection Week

As National Consumer Protection Week begins, the impact of Pennsylvania's new centralized consumer protection initiative — which has already connected thousands of Pennsylvanians with help resolving scams, insurance disputes, and financial concerns, is being highlighted.

Since launching the statewide "no wrong door" consumer protection hotline, website, and email address in May 2025, more than 10,000 consumers have visited pa.gov/consumer and hundreds of Pennsylvanians have called 1-866-PACOMPLAINT or emailed consumer@pa.gov seeking assistance.

The initiative connects consumers with agencies including:

Department of Banking and Securities (DoBS) – Protecting against financial exploitation, predatory lending, and banking issues.

Pennsylvania Insurance Department (PID) – Resolving disputes over claims, coverage, and unfair insurance practices.

Other agencies regulating utilities, student loans, and professional licensing.

In 2025 alone, DoBS managed more than 11,000 consumer inquiries and conducted over 300 outreach events reaching nearly 53,000 Pennsylvanians with financial education and investor protection information.