Court grants judgment against Aetna in NJ case

New Brunswick, N.J.鈥擳he New Jersey Dental Association and a member dentist last month won a suit against Aetna Life Insurance Co. regarding its processing of an overpayment.

Acting as a third-party administrator, Aetna withheld an overpayment it made to a nonparticipating dentist for a patient covered by one ERISA plan from the benefits payable to the dentist for members of other ERISA plans.

“We want to send the message to Aetna and other carriers that when dental claims are dealt with in a manner that is inconsistent with the law, the dental society is prepared to take action,” commented Art Meisel, NJDA executive director. “The court agreed that Aetna did not act within the scope of the mandates of the plan.”

The Superior Court of New Jersey found in favor of the NJDA and Dr. Michael A. Dill, saying “Aetna Life Insurance Co., as the administrator for an ERISA benefit plan, cannot recoup any payment erroneously made to a provider of services from any other amount payable to the provider under another ERISA benefit plan except as the plans themselves may provide.”

State laws regulating insurers didn’t apply in the case as Aetna was acting as a third-party administrator for an ERISA benefit plan. State laws are often pre-empted by the Federal Employee Retirement Income Security Act.

Mr. Meisel said the NJDA sought a declaratory judgment, “so the decision would have an impact beyond the claims filed for just one doctor.”

A declaratory judgment is a court decision in a civil case that tells the parties what their rights and responsibilities are regarding the dispute. The plaintiff in a declaratory judgment case wants the court to resolve an uncertainty rather than seek damages or court orders. The amount in controversy was $77.60.

“The NJDA is very supportive of the rights of its members and felt action should be taken so claims could be correctly processed and appropriately paid,” said Mr. Meisel. The law firm representing Aetna in the case鈥擪elley, Wardell, Craig, Annin and Baxter鈥攄id not respond to requests for comment by ADA News.

The decision applies only to nonparticipating dentists because participating dentist agreements typically contain a clause requiring that overpayments or payments made in error be returned by the participating dentist.