Aetna Life Insurance $2.56M L-ADR Surgery Denial Settlement

Patients covered under an Employee Retirement Income Security Act of 1974-governed health plan that Aetna administered or insured and whom Aetna denied a request or claim for single-level lumbar artificial disc replacement surgery may be eligible to claim a cash payment from a class action settlement.

Aetna Life Insurance Co. agreed to resolve a class action lawsuit alleging it improperly denied coverage for single-level L-ADR surgeries under ERISA-governed health plans.

Who can file a claim?

Individuals may be eligible if:

• An Aetna health plan governed by ERISA (either self-funded or fully insured) covered them.
• Aetna denied a request or claim for single-level L-ADR as experimental or investigational between:
• Aug. 7, 2016, and Feb. 8, 2023, for the Hendricks action (subject to abuse of discretion review), or
• March 4, 2019, and Feb. 8, 2023, for the Howard action (subject to de novo review)

• They received a mailed notice about the settlement.

The class includes:

• People who paid out of pocket for single-level L-ADR surgery after Aetna denied coverage
• People whom Aetna denied coverage but have not yet had the surgery and are still covered by an ERISA-governed Aetna plan
• People whom Aetna denied coverage, have not had the surgery and are no longer covered by an ERISA-governed Aetna plan but do not have other coverage for L-ADR and cannot reasonably obtain such coverage

Who is excluded from the class?

• Those who had coverage for single-level L-ADR through another health plan, insurer, Medicare or another reimbursement source for which they owe no reimbursement obligation (other than applicable deductible, copays or coinsurance) or who have a reasonable ability to enroll in individual health coverage that provides coverage for single-level L-ADR
• Anyone whose denial occurred after Feb. 8, 2023

How much can class members get?

The settlement provides three main forms of relief:

• Reimbursement for past surgeries: Patients who paid out of pocket for a single-level L-ADR surgery that Aetna denied may receive reimbursement up to $55,000 for documented payments.
• Coverage for future surgery (current Aetna members): Patients who are still covered by an ERISA-governed Aetna plan and have not yet had the surgery can submit a new request for coverage. If their surgeon attests that the procedure is medically necessary, Aetna will review their request under the terms of the settlement.
• Reimbursement for future surgery (former Aetna members): Patients who are no longer covered by an ERISA-governed Aetna plan, have not had the surgery and do not have other coverage for L-ADR (and cannot reasonably obtain such coverage) may be eligible for reimbursement up to $55,000 for a future single-level L-ADR surgery. The settlement administrator can make the payment directly to the patient or to the surgeon.

Key details:

• The reimbursement does not cover copays or coinsurance if another plan covers the surgery.
• Reimbursement is only for net out-of-pocket payments to medical providers for the surgery.

How to claim a settlement payment

To claim a settlement payment, eligible class members must file a claim. They can file a claim online, or the settlement administrator will mail claim forms to eligible class members after the court grants final approval of the settlement. Those who prefer to mail their claim can send the required documentation to the settlement administrator.

Settlement administrator's mailing address: Hendricks/Howard v Aetna Life Insurance Co., c/o Atticus Administration, PO Box 64053, St. Paul, MN 55164

Is proof or documentation required to submit a claim?

Yes. Claimants must provide documentation to support their claim. Required documentation includes:

• Proof of having a single-level L-ADR surgery (such as an operative report, clinical records or detailed payment records)
• Proof of payment (checks, wire transfer receipts, invoices showing actual payment or other reasonable proof)
• A statement of the specific amount of unreimbursed out-of-pocket costs being claimed

For future surgeries, claimants must provide an attestation from their treating surgeon that the planned single-level L-ADR is medically necessary.

• For reimbursement of past surgeries: Submit claim form, proof of surgery, proof of payment and statement of unreimbursed costs
• For coverage of future surgery (current Aetna members): Submit claim form and surgeon’s attestation or letter of medical necessity
• For reimbursement of future surgery (former Aetna members): Submit claim form, surgeon’s attestation or letter and proof of payment after surgery

If the settlement administrator denies the claim for lack of documentation, the class member will have 60 days to provide additional information. If they receive an unfavorable decision, they may request reconsideration within 60 days. Class counsel and Aetna’s counsel will attempt to resolve the issue and, if unresolved, will present the matter to the court for a final decision.

Payout options

• The settlement administrator will send reimbursement checks directly to the class member.
• For future surgeries, the administrator can make a payment directly to the treating surgeon or or reimburse the class member after they make a payment.

$2.56 million settlement fund breakdown

The $2,560,000 settlement fund covers:

• Settlement administration costs: To be determined
• Attorneys’ fees and expenses: Up to $2,556,000
• Service awards to class representatives: $17,000 each for two representatives and $10,000 for a third representative ($44,000 total)

Aetna will pay class members' reimbursement and coverage relief costs separately from the settlement fund.

Important dates

• Request for exclusion deadline: Feb. 17, 2026
• Final approval hearing: June 5, 2026
• Former member claim deadline: Aug. 11, 2026
• Reimbursement claim deadline: Sept. 10, 2026
• Current member claim deadline: Dec. 9, 2026

When is the LADR surgery settlement payout date?

The settlement administrator will issue settlement checks within 60 days after it completes the reconsideration process.

For new requests for coverage by former members of Aetna, Aetna will pay the class member's medical provider directly for the services relating to a single-level ADR within 90 days of receiving the required proof. Alternatively, if the class member pays the medical providers directly, they will receive reimbursement upon receipt of the required proof.

Why did this class action settlement happen?

This class action lawsuit alleged Aetna Life Insurance Co. denial patient requests for coverage of lumbar artificial disc replacement surgery because it deemed it experimental and investigational.

Aetna denied the allegations but agreed to settle to avoid the expense and risk of continued litigation and a possible trial.

Sources

1. Hendricks notice
2. Howard notice
3. Important dates
4. Settlement FAQ
5. Settlement agreement