Aetna Health of California routinely and illegally denies patients access to out-of-network ambulatory surgical centers after selling them costly insurance policies that promise them the right to chose where and from whom they get medical care, according to a lawsuit filed today by the Los Angeles County Medical Association (LACMA), California Medical Association (CMA), Santa Clara County Medical Association, Ventura County Medical Association, patients and other health care providers.
The lawsuit, filed in Los Angeles County Superior Court, alleges a systematic practice by Aetna of threatening patients with denial of promised coverage if they seek medical care at surgery centers outside the Aetna network, and threatening in-network doctors with contract termination if they refer patients outside the network. The insurance company has carried out both these threats in many cases, according to the suit.
"Aetna is putting profits ahead of patient's health and safety; that's immoral and too often it is also illegal,” said Rocky Delgadillo, LACMA CEO and former Los Angeles City Attorney. "The insurance company interferes not only with doctor-patient relationships, but also harms the ability of California health care providers to get sick people the care they need in a professional and timely manner.”
The allegations against Aetna include false advertising, breach of contract, unfair business practices, and both intentional and negligent interference with health care providers. CMA and the county medical associations are involved in the lawsuit to protect the interests of individual physicians and to seek injunctive relief that would force Aetna to change its unlawful business practices.
The lawsuit comes just three months after California Insurance Commissioner Dave Jones criticized Aetna's quarterly health insurance rate increases as "unreasonable” and "in excess” of the U.S. Bureau of Labor's medical cost inflation index. Aetna, the commissioner said, "is hitting its California small employer customers with an average increase of 30.3 percent over the last 24 months.”
"Despite making tens of millions of dollars selling policies with out of network benefits,” the lawsuit says, "Aetna has engaged in a campaign to retaliate against its members who attempt to use their out-of-network benefits, and the physicians who refer these members to out-of-network providers.”