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This document is a Consent Agreement, authorized by 10 M.R.S.A. § 8003(5)(B), entered into by and among Aetna Health, Inc. (hereafter also “Aetna”), the Superintendent of the Maine Bureau of Insurance (hereafter “the Superintendent”), and the Office of the Attorney General. Its purpose is to resolve, without resort to an adjudicatory proceeding, Aetna’s failure to respond to an inquiry from the Superintendent within 14 days pursuant to 24-A M.R.S.A. § 220(2).
1. The Superintendent is the official charged with administering and enforcing Maine’s insurance laws and regulations.
2. Aetna is a Maine licensed HMO, license # HMD 45749, NAIC # 95517.
3. Title 24-A M.R.S.A. § 220(2) provides: “Response to inquiries. All insurers and other persons required to be licensed pursuant to this Title shall respond to all lawful inquiries of the superintendent that relate to resolution of consumer complaints involving the licensee within 14 days of receipt of the inquiry and to all other lawful inquiries of the superintendent within 30 days of receipt. If a substantive response can not in good faith be provided within the time period, the person required to respond shall so advise the superintendent and provide the reason for the inability to respond.”
4. An Aetna policyholder filed a written complaint with the Bureau on August 27, 2004 regarding a denial of benefits. The Bureau sent a letter to Aetna dated on August 30, 2004 requesting a written response to the policyholder’s complaint within 14 days.
5. Aetna’s September 15, 2004 response to the Bureau stated, in part:
6. The Bureau sent a letter to Aetna dated September 15, 2004, stating in part:
7. As of October 22, 2004 the Bureau has not received a substantive response to the September 15, 2004 letter to Aetna.
CONCLUSIONS OF LAW
8. Aetna failed to respond to the Superintendent’s September 15, 2004 inquiry within 14 days as required by Title 24-A M.R.S.A. § 220(2).
9. A formal hearing in this matter is waived and no appeal will be made.
10. At the time of executing this Agreement, Aetna shall pay to the Maine Bureau of Insurance a penalty in the amount of two hundred dollars and No Cents ($200.00) payable to the Treasurer of the State of Maine.
11. In consideration of Aetna's execution of and compliance with the terms of this Consent Agreement, the Superintendent agrees to forgo pursuing any disciplinary measures or other civil sanction for the specific violations described above other than those agreed to in this Consent Agreement.
12. This Consent Agreement may only be modified by the written consent of the parties.
13. It is understood by the parties to this Agreement that nothing herein shall affect any rights or interests of any person not a party to this Agreement.
14. Aetna acknowledges that this Agreement is a public record within the meaning of 1 M.R.S.A. § 402, that this Agreement will be available for public inspection and copying as provided for by 1 M.R.S.A. § 408, and that this Agreement will be reported to the NAIC and included in the RIRS database.
15. Aetna has been advised of its right to consult with counsel and has, in fact, consulted with counsel before executing this Agreement.
16. Nothing herein shall prohibit the Superintendent from seeking an order to enforce this Agreement, or from seeking additional sanctions in the event that Aetna does not comply with the above terms, or in the event that the Superintendent receives evidence that further legal action is necessary.
Subscribed and sworn to before me
Last Updated: October 22, 2013
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