AETNA OUT-OF-NETWORK BENEFITS: Los Angeles County Medical Association (LACMA), California Medical Association (CMA) et. al. v. Aetna (Los Angeles Superior Court, Case No. BC487412)
On July 3, 2012, LACMA, CMA, Santa Clara County Medical Association, Ventura County Medical Association, along with a coalition of health care organizations and providers filed a lawsuit against Aetna to protect the rights of patients and doctors to quality healthcare and to prevent insurers from interfering with patient choice. The lawsuit alleges a systematic practice by Aetna of harassing and terminating contracted doctors from the Aetna network when they refer patients to an out-of-network ASC.
After nearly seven years of protracted litigation, in April 2019 all plaintiffs agreed to dismiss their claims and Aetna agreed to abandon its counterclaims, so that the lawsuit can be streamlined for CMA to proceed as the sole plaintiff. CMA will seek injunctive relief on the basis that California law prohibits Aetna from terminating contracted physicians for referring patients out of network when those patients have PPO out-of-network benefits; Aetna claims physicians must abide by contractual provisions requiring use of in-network facilities.
In November 2019, the LA Superior Court ruled that CMA did not have legal standing to pursue its claims against Aetna on behalf of itself and its physician members. CMA is exploring appealing the decision, which may have broad implications on CMA's and other advocacy organizations' ability to pursue remedies in the courts.