Family Sues Aetna, Employer Over Failure to Cover Substance Abuse Treatment

On Friday, three plaintiff family members filed a complaint in the Northern District of California against Aetna Life Insurance Company, SHI International Corporation, and Does 1 through 10 for recovery of medical plan benefits.

Clayton and Liz Wallace are the parents of Zachary Wallace.  Clayton is employed by defendants SHI. All three plaintiffs are ensured under the SHI medical plan administered by defendant Aetna.  The plan is governed by the Employee Retirement Income Security Act of 1974 (ESRA).

The disputed health insurance claim is related to allegedly medically necessary substance abuse treatment received by the plaintiff Zachary from December 2018 through May 2020. 

The Wallaces claim that the defendants refused to pay a valid health insurance claim for Zachary’s medical treatment and Aetna arbitrarily reduced payment for certain medical claims and refuse to pay other claims completely. Per the plaintiffs, Aetna also refused to review the claims as required by ERISA.  Aetna allegedly failed to provide the plaintiffs with written notice of the refusal to pay for the majority of the health claims.  This resulted in the plaintiffs facing nearly $200,000 in unpaid medical bills for services that allegedly should have been covered by Clayton’s plan.

The plaintiffs are represented by The McKennon Law Group. This instant action is brought under ERISA for recovery of ERISA plan benefits, enforcement and clarification of rights, prejudgment interest, and attorney’s fees.    

The Wallaces are seeking declaratory judgement in their favor; all plan benefits due and owing to them, costs and reasonable attorneys’ fees, and pre-judgement and post-judgement interest on the principal sum accusing from the date the obligations were incurred.