Aetna, ConnectiCare and Harvard Pilgrim have the highest denial rates among individual health insurance policies sold through Access Health Exchange.
A review of 2023 data from the state’s Insurance Department found the three companies deny claims at rates above the statewide average for both HMO and indemnity plans.
Aetna had the highest denial rates for HMO plans, at 39.4%, followed closely by Harvard Pilgrim, at 38.8%, and Connecticare, at 33.6%.
The statewide average for six companies selling HMO plans was 29%.
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People can appeal their denials, but the data shows that doesn’t happen often.
Aetna reported no appeals from HMO customers in 2023. ConnectiCare had just 19 appeals of its 169,457 denials and Harvard Pilgrim had 12 appeals of its 8,257 denials.
Of those, Connecticare reversed six denials. Harvard Pilgrim reversed five.
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Aetna responded by noting that its customer satisfaction scores were among the highest in the report.
NBC Connecticut reached out to some of the other companies selling policies in the exchange but received no response.
Insurers also sell indemnity plans, a more typical fee-for-service type of insurance.
ConnectiCare, selling plans as both ConnectiCare and ConnectiCare Benefits, had a combined denial rate of 29.7% for its 4.7 million claims.
Aetna was second with a rate of 28.2%, while Harvard Pilgrim’s rate was 23.3%. The statewide average for eight companies offering indemnity plans was 21.5%.
One other company exceeded that rate: Connecticut General had a denial rate of 22.8% on 272 indemnity claims in its first year of offering individual plans in Connecticut.
Connecticare reversed only 283 of its denials. Aetna reversed 10 of its 181,642 denials, while Harvard Pilgrim did so for nine of its 23,605 denials.
Individual plans account for only roughly one-fourth of all health insurance plans in the state, but Connecticut Center for Patient Safety Lisa Freeman says the numbers are indicative of a bigger problem.
“I'm not surprised only because I realize how convoluted and challenging dealing with our healthcare system is,” Freeman said about the low number of appeals.
She said people find it difficult navigating the process for appealing a decision. Many just give up.
She said people can find help, including by asking their doctor or reaching out to the Insurance Department.
They can also contact a group like Freeman’s advocacy organization.
Freeman also said people should include their doctor in the process, even if they file an appeal on their own.
This is especially true when insurance companies deny coverage for treatment that is deemed unnecessary.
“They do want to hear from your physician, your provider as why it’s deemed medically necessary,” Freeman said.
