Graduate Student Health Insurance - "Aetna can deny your claim for any reason"?

Question

Has anyone here had insurance through Aetna/The Chickering Group? If so, did you have any reasonable claims denied?

Answer 1

The basis of your health insurance is a legally enforceable contract. Aetna, or any other insurance company for that matter, cannot deny your claim for "any reason".

The denial has to be based on the terms of the contract. That contract broadly specifies what is covered in an insuring agreement (i.e. we will cover medically necessary procedures). The insuring agreement is then modified by the exclusions.

So for the company to deny any "reasonable" claim the procedure has to be outside of what is agreed to in the insuring agreement (such as cosmetic surgery) or it has to be specifically excluded.

Read your contract.