Federal Appeals Court Deals a Blow to Aetna on Various Issues in Health Insurance Case


The United States Court of Appeals for the 5th Circuit ruled in favor of a health plan’s HMO member and against Aetna regarding a claim for out of network benefits.  In an extensive opinion, the court ruled against Aetna on various legal issues that could set a precedent for the benefit of health plan members under HMOs and other plans nationwide.

The Court, in Koehler v. Aetna, first ruled that Aetna’s summary of the health plan violated ERISA, the federal law that governs most group health insurance in the United States. The language was difficult, vague, and confusing, so the court ruled that any benefit of the doubt when interpreting the summary should go to the plan member and not Aetna, the drafter of the unlawful summary. The Court then ruled that pre-approval for certain medical services was not required because the pre-approval terms in the plan’s summary were not clear and understandable, in violation of the ERISA regulations.

The Court also barred Aetna from raising late defenses and indicated that the plan member did not have to appeal Aetna’s denial because of the regulatory violations.

Schwartz, Conroy & Hack is in the forefront in representing medical providers and hospitals in pursuing denied health plan claims and addressing “audits” on closed and paid claims. For more information, please contact us at 800 745 1755 or complete the contact form on this site.

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Evan S. Schwartz
Founder of Schwartz, Conroy & Hack