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Aetna Sued for Failing to Pay for Out of Network COVID-19 Testing

A rendition of amicroscopic coronavirus.

Coronavirus. COVID-19. 3D Render

California company Saloojas, Inc. doing business as AFC Urgent Care of Newark filed a class-action complaint against Aetna Healthcare of California on Monday in the Northern District of California for allegedly failing to fully cover and reimburse the plaintiff for its members’ COVID-19 diagnostic testing.

According to the complaint, Aetna “engaged in unconscionable and fraudulent conduct during the COVID-19 public health emergency period in order to evade and circumvent its obligations to fully cover all Aetna Plan members’ COVID-19 diagnostic testing services and to reimburse Plaintiff, an out-of-network (OON) laboratory, for bona fide Covid Testing services” offered to Aetna’s members in compliance with the federally set method established in the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, Economic Security Act (CARES Act).  

The plaintiff highlights the importance of COVID-19 testing during the global pandemic as a way to help mitigate the spread of the virus. The plaintiff notes that congress passed both the FFCRA and the CARES Act in an effort to address the country’s need for testing and to “address issues pertaining to the costs of and access to Covid Testing during the COVID-19 pandemic.”

The plaintiff asserts that Aetna’s purported conduct has hindered efforts to reduce the spread of the virus because it has caused AFC Urgent Care and other similarly situated OON providers to cease “specimen collection and testing locations and to potentially stop offering Covid Testing services altogether.” The plaintiff contends that Aetna’s mis-processing and denial of Covid Testing claims is causing it to have a huge financial loss and forced it to deplete its own funds to cover this loss. AFC Urgent Care purports that Aetna has mis-adjudicated almost every claim the plaintiff submitted and denied the vast majority of the Covid Testing claims it submitted.

AFC Urgent Care claims that Aetna’s conduct as an insurer and third-party claims administrator has “had a material adverse effect on the nation’s response to the COVID-19 pandemic as it has largely diminished access to testing, shifted financial responsibility” to Aetna’s members and has caused the plaintiff and others to be hesitant to work with Aetna and in the case of another pandemic to lessen the likelihood the plaintiff will participate in federal or state efforts.

The plaintiff states that it tried to contact Aetna about its conduct and to negotiate with the insurance provider for a means of reimbursement in addition to providing Aetna with notice of its purportedly unlawful behavior; however, these efforts have not been fruitful.

AFC Urgent Care claims that Aetna violated the FFCRA, the CARES Act, the Employee Retirement Income Security Act of 1974, the Racketeer Influenced and Corrupt Organizations Act as well as California state law.

The plaintiff is asking to represent a nationwide class for entities that are out of network providers to Aetna.

The plaintiff seeks declaratory judgment for Aetna’s purported violations; treble, punitive, compensatory, consequential and other damages; California statutory interest; pre- and post-judgment interest; an award for costs and attorneys’ fees; and other relief.  

The plaintiff is represented by the Law Office of Michael Lynn Gabriel.

This lawsuit appears to be part of a larger campaign against Aetna as Saloojas has filed a total of eight lawsuits against Aetna, seven of which were in March 2022. These are all statutory actions-other case types. This year Aetna has faced 14 from January 2021 to now, nine of these types of lawsuits were filed thus far in 2022, most of which were from the plaintiff.

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