The Pennsylvania Insurance Department announced the results of a market conduct exam on Aetna that found several violations by the health insurance company that negatively impacted policyholders. As a result, the company must pay a $550,000 penalty, fix its practices, and repay affected Pennsylvanians.
“This announcement represents just one of the many ways PID protects consumers. Our front-end compliance reviews and back-end enforcement is among the most robust in the country, and we will continue to enforce Pennsylvania laws and regulations to the fullest extent of our statutory authority,” said Pennsylvania Insurance Commissioner Michael Humphreys.
The Aetna exam covers the period from October 1, 2021, through December 31, 2022. A Consent Order was signed in January 2026. The full report can be found on PID’s website.
PID’s exam found:
- Incomplete claims files, especially for Autism Spectrum Disorder (ASD) services;
- Delays in approving or denying claims and failure to explain those delays;
- Improper claim denials due to poor internal communication about prior approvals and other insurance coverage;
- Failure to clearly explain member cost-sharing for ASD services; and
- Violations of mental health parity laws, including incorrect or incomplete analysis and application of benefit limits.
PID also found broader “universe” violations. These included flawed methods for reviewing mental health parity compliance and failure to clearly list cost-sharing for ASD services in most plans. The company also confirmed it was not sending required claim delay letters during the exam period.
Under the Consent Order, Aetna must:
- Reprocess claims that were handled incorrectly and pay members what they are owed, with interest;
- Improve internal systems to make sure claims are processed correctly and on time;
- Clearly explain cost-sharing in benefit documents;
- Fix denial letters so they clearly explain why services were denied, especially for Applied Behavior Analysis services for ASD; and
- Reprocess claims that did not meet mental health parity requirements and provide proof of repayment to PID.
Aetna must complete most of these corrective actions within 12 months, with regular reports to PID.
