Problem Solver: Aetna Claim Denial

When a surgery leaves you out of work the last thing you want to do is go to battle about your short-term disability claim. But when one Upstate woman's fight became more than she could handle 7 On Your Side went to bat for her. Dianne Derby helps turn that denial in her favor and tells you what you can do to fight back against a denial. It's a 7 On Your side Problem Solver.

When the pelvic pain Helen Cochran had continued to cause her severe pain she and her doctor decided to schedule a hysterectomy. She says he told her she needed to be out of work for two weeks prior to the surgery. But when she filed for short-term disability Aetna, the claims processor, denied her claim.

"I don't know why they denied it," Cochran said. "Everything they said was there was just not enough information."

But she says she had three notes from her doctor saying she had to be out of work. She says her job at BMW's manufacturing plant was too intense to deal with the pain...

"I'm basically in the sanding department to get away the defects and repaint them," said Cochran. "Your're on your feet 10 hours a day we get two ten minute breaks and a 40 minute lunch."

Plus she worried about the dangers of being on prescription pain medication.

"It would be dangerous you know working with other associates working with machinery anything could happen," said Cochran.

So we contacted Aetna to see why the claim was denied. They tell us Cochran was seeing two doctors, her surgeon and an OB/GYN specialist. Her surgeon wrote the doctors notes for the time off. But Aetna says her OB/GYN specialist saw her on the days in question and did not provide documentation that she needed the time off.

"As soon as I called you they called me for the very first time," said Cochran.

After we called Aetna did decide to reverse their decision for one of the two weeks of her absence from work. Aetna spokesperson Cynthia Michener wouldn't comment to us during a phone interview instead in an e-mail she said they were going to be as fair as possible in the review of her claims and "err on the side of the employee". Michener went on to say, "During that review, we determined that a prescription for pain medication could be viewed in the employee's favor as a reason to be out of work prior to surgery, combined with the other documentation."

While Helen is glad she is being covered for one week she says she plans to continue her fight for full coverage for all time off.

We all know how frustrating it is to have a health claim wrongly denied. So we're on your side with what you should do if this happens to you.
--Follow the appeals process for your plan.
--If that doesn't work file a complaint contact the South Carolina Department of Insurance. For a link to the complaint form click here.