HARRISBURG, PA — Aetna must pay a $550,000 penalty and repay Pennsylvania policyholders after state regulators found multiple violations in how the company handled insurance claims, including delays, improper denials, and failures tied to mental health coverage rules.
What This Means for You
- Aetna must repay affected policyholders and correct claim decisions that were handled improperly.
- The company was fined $550,000 and ordered to change how it processes claims and communicates with customers.
- Consumers who believe their insurance claims were mishandled can file a complaint with the Pennsylvania Insurance Department.
The Pennsylvania Insurance Department announced the findings following a market conduct exam, an investigation regulators use to review whether insurance companies are following state laws and properly serving policyholders.
The review examined Aetna’s claims handling and internal practices from October 1, 2021, through December 31, 2022. A Consent Order — a legally binding agreement requiring the company to correct violations — was finalized in January 2026.
Claims Handling Problems Identified
The department found several issues that affected policyholders, particularly in claims related to Autism Spectrum Disorder services.
Autism Spectrum Disorder is a developmental condition that affects communication, behavior, and social interaction. Many health plans cover specialized treatments such as Applied Behavior Analysis, a therapy used to improve communication and learning skills.
According to regulators, the exam identified incomplete claims files, delays in approving or denying claims, and failures to explain those delays to customers.
Investigators also found cases where claims were denied improperly because of internal communication errors, including confusion about prior approvals or other insurance coverage.
In addition, the department said some plans did not clearly explain cost-sharing requirements — the portion of medical costs patients must pay themselves through deductibles, copayments, or coinsurance.
Mental Health Parity Violations
Regulators also identified violations of mental health parity laws.
Mental health parity laws require insurance plans to cover mental health and substance use treatment at levels comparable to physical health services. This means insurers cannot impose stricter limits or higher costs for mental health care than for other medical treatment.
The Insurance Department said Aetna used flawed methods when evaluating whether its plans met these parity requirements and failed to provide proper analyses of benefit limits.
Insurance Commissioner Michael Humphreys said the enforcement action is part of the state’s broader effort to ensure mental health coverage is treated equally under the law.
“A few years ago, Governor Shapiro tasked PID with making mental health parity a true reality for Pennsylvanians,” Humphreys said. “Today’s announcement is another giant step toward that ultimate goal.”
Required Fixes and Repayments
Under the Consent Order, Aetna must correct several practices identified in the investigation.
The company is required to reprocess claims that were handled incorrectly and repay affected members, including interest on the amounts owed.
Aetna must also update its internal systems to ensure claims are processed correctly and on time, revise denial letters to clearly explain why services were rejected, and clarify cost-sharing details in its benefit documents.
In addition, the company must reprocess claims that did not meet mental health parity standards and provide proof to regulators that affected policyholders were reimbursed.
Most corrective actions must be completed within 12 months, with the company submitting regular compliance reports to the Pennsylvania Insurance Department.
How Consumers Can File a Complaint
Residents with questions about their health insurance coverage or who believe their claims were handled improperly can contact the Pennsylvania Insurance Department.
Complaints can be submitted online at:
pa.gov/consumer
Consumers can also call the department’s complaint hotline at 1-866-722-6675.
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