Aetna U.S. Healthcare
Out-of-Network Surgeon Claim Paid at 70 Percent and Appeal Unanswered

On Sept. 29, I was hospitalized for acute abdominal pain and a large mass in my abdomen—after CT scan it was confirmed as acute diverticulitis and generalized peritonitis, which is life-threatening.

My family physician referred me to an excellent surgeon who I did not know at the time was "out-of-network." I realized this after my claim was only paid at 70%, instead of 90% for "in-network" provider.

There is a clause in my insurance that states the "in-network" amount will be paid when the patient is admitted through emergency and surgery is performed within 24 hours. Surgery was performed within 24 hours of my CT scan—why would any surgeon blindly perform surgery without the benefit of a CT scan?

It is my belief, as well as my surgeon's, that this claim should have been paid at the in-network amount because of the circumstances. Therefore, I mailed a request (certified) for review/appeal on December 13. It is now more than 60 days and I have heard nothing from them.

They have also failed to apply ostomy supplies to our deductible. It does not pay to be sick in America.

I will pursue this matter indefinitely, if need be. Aetna has put me and my family in extreme financial and mental hardship.

Company: Aetna U.S. Healthcare
Country: USA
State: New York

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