American Dental Association files Class Action Suit
Against Aetna USHealthcare
 CHICAGO,
Aug. 16 /U.S. Newswire/ -- The American Dental Association (ADA) and
two of its member dentists sued Aetna yesterday, charging the
giant insurer with breach of contract, libel and unlawful interference
with the dentist-patient relationship. Filed here in U.S. District
Court for the Northern District of Illinois, the class-action complaint
seeks relief under the Employee Retirement Income Security Act (ERISA)
for breach of contract, and under supporting state laws for the
trade libel and tortious interference charges.
The plaintiffs charge Aetna,
the nation's third largest provider of dental coverage, with regularly
breaching its contract with subscribers by failing to pay non-plan providers'
actual charges for professional services rendered.
According to the complaint,
Aetna's contract with its subscribers states that the insurer is required
to pay out-of-network providers' actual charges unless it has appropriate
data to substantiate a lower payment. The lawsuit claims Aetna did not
substantiate the lower payments and misrepresented how it arrived
at determining usual,
customary and reasonable (UCR) amounts it paid to out-of-network providers.
The complaint says the company knew or had reason to know the lower
amounts it paid were below proper UCR amounts.
The lawsuit also charges Aetna
with using language on its Explanation of Benefits (EOB) form, which is
sent to patients, to tell patients of the out-of-network dental provider
that it would not pay the dentists' actual charges because the "provider
has engaged in misconduct by attempting to
charge excessive and unreasonable
fees."
Aetna subscribers would not
have known that the insurer had not appropriately determined that the
out-of-network provider's actual charges were unusual or more than proper
UCR amounts, the complaint charges. "By deliberately disseminating
misinformation about individual dentists and their fees, we believe Aetna
has seriously undermined the trust between dentists and their patients
by casting doubt on their integrity and professionalism," said Dr. Robert
M. Anderton, ADA president. "This also
constitutes trade libel, and
dentists have lost long-standing patients through such misleading information. Some patients, believing their dentist attempted to charge an excessive
fee, chose to go elsewhere or have even elected to forego treatment altogether. "
The plaintiffs seek an injunction
to prohibit Aetna from continuing to engage in the allegedly unlawful
business practices, and awarding of compensatory and punitive damages.
The not-for-profit ADA is the nation's oldest national dental association,
representing more than 141,000 members. It advocates for public health
and promotes the art and science of dentistry. ADA member
dentists have a commitment
to provide high-quality oral health care and promote accessible oral
health care to everyone.
The complaint is available
online at www.ada.org.
Contact: Fred Peterson or Leslee Williams, 312-440-2806
Both of the American Dental Association
E-mail: petersonf@ada.org; Williamsle@ada.org
|
