XXXXX File No Petitioner v. Issued and entered this 1st day of July 2010 by Ken Ross Commissioner ORDER I PROCEDURAL BACKGROUND

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1 In the matter of STATE OF MICHIGAN DEPARTMENT OF ENERGY, LABOR & ECONOMIC GROWTH OFFICE OF FINANCIAL AND INSURANCE REGULATION Before the Commissioner of Financial and Insurance Regulation XXXXX File No Petitioner v Aetna Life Insurance Company Respondent / Issued and entered this 1st day of July 2010 by Ken Ross Commissioner ORDER I PROCEDURAL BACKGROUND On March 9, 2010, XXXXX (Petitioner) filed a request for external review with the Commissioner of Financial and Insurance Regulation under the Patient s Right to Independent Review Act, MCL et seq. The Commissioner notified Aetna Life Insurance Company (Aetna) of the external review and requested the information used in making its adverse determination. On March 16, 2010, the Office of Financial and Insurance Regulation received the information and accepted the case for review. The Petitioner has group health care coverage. Her benefits are defined in Aetna s MI Open Choice PPO 3-07 Certificate of Coverage (the certificate). The issue here can be decided by applying the terms of the certificate. The Commissioner reviews contractual issues pursuant to MCL (7). This matter does not require a medical opinion from an independent review organization.

2 Page 2 II FACTUAL BACKGROUND The Petitioner experienced bilateral foot pain and was diagnosed as having calcaneal varus and Morton s neuroma in the left and right foot. As a result of these diagnoses, she was casted for custom foot orthotics on December 21, Upon receiving the claim for the custom orthotics, Aetna denied coverage on the basis that they are excluded from coverage. The Petitioner appealed the denial. After completing Aetna s internal grievance process, the Petitioner received Aetna s final adverse determination dated March 4, 2010, upholding its original decision. III ISSUE Did Aetna correctly process the claim for Petitioner s foot orthotics? Petitioner s Argument IV ANALYSIS The Petitioner says she contacted Aetna for precertification of the foot orthotics and was told they would be 100% covered. She also says an Aetna customer service representative verified that the medical diagnosis code she received from her physician was correct and would be accepted; now Aetna will not honor what it told her. The Petitioner wants Aetna to cover her foot orthotics. Respondent s Argument Aetna, in its March 4, 2010, final adverse determination, told the Petitioner: According to the MI Open Choice PPO 3-07 Summary Plan Description (SPD) under Other Medical Expenses; a list of covered medical expenses include; Artificial limbs and eyes. Not included are charges for: orthopedic shoes, foot orthotics, or other devices to support the feet, unless necessary to prevent complications of diabetes.

3 Page 3 The Certificate of Coverage specifically indicates that foot orthotics or other devices to support the feet are not a covered benefit unless necessary to prevent complications of diabetes. According to our records there is no indication that you are diabetic. Aetna s Medical Clinical Policy Bulletins apply to all medical benefit plans and are used in conjunction with the terms of the member s benefit plan and other Aetna-recognized criteria to determine health care coverage for Aetna s members. However, since the plan specifically states the foot orthotics are not covered except in cases to prevent diabetic complications, the Clinical Policy Bulletin would not apply in this case. Aetna contends its benefit determination for Petitioner s claim was in compliance with the terms of the certificate. Commissioner s Review The certificate, in the section Comprehensive Medical Expense Coverage, contains this language (pp. 5, 11-12): Here is a list of Covered Medical Expenses. Other Medical Expenses Charges for the following Artificial limbs and eyes. Not included are charges for: eyeglasses; vision aids; hearing aids; communication aids; and orthopedic shoes, foot orthotics, or other devices to support the feet, unless necessary to prevent complications of diabetes. [Underlining added] This provision is clear: there is no coverage for foot orthotics under the Petitioner s certificate unless they are necessary to prevent complications from diabetes. Neither the Petitioner

4 Page 4 nor her physician said that she had diabetes and there is nothing in the record to indicate that the foot orthotics were prescribed to prevent complications of diabetes. The Commissioner therefore concludes that Aetna correctly denied coverage under the terms and conditions of the certificate. The Petitioner argues that her foot orthotics should be covered because she was misinformed by Aetna s representatives, impliedly saying that she detrimentally relied on Aetna s representations that the orthotics would be covered. However, Aetna says it reviewed the calls and found nothing to indicate that the Petitioner was told Aetna would cover the foot orthotics. This kind of dispute cannot be resolved under the Patient s Right to Independent Review Act (PRIRA) because the act does not provide for the type of hearing that would allow the Commissioner to make fact-findings based on oral statements. Moreover, even if it is true that Aetna misinformed the Petitioner, the Commissioner cannot order the relief she requests. Under PRIRA, the Commissioner s role here is limited to determining if the health care service is covered under the certificate or required by state law. See MCL The Commissioner, unlike the circuit courts of this state to which PRIRA orders may be appealed, does not have the authority to order equitable relief as part of a decision in this case. The Commissioner finds Aetna correctly processed Petitioner s claim according to the terms of the certificate. V ORDER The Commissioner upholds Aetna s final adverse determination of March 4, Aetna is not required to provide coverage for the Petitioner s foot orthotics provided on December 21, This is a final decision of an administrative agency. Under MCL , any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order

5 Page 5 in the circuit court for the county where the covered person resides or in the circuit court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of Financial and Insurance Regulation, Health Plans Division, Post Office Box 30220, Lansing, MI