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Aetna and The Rawlings Company LLC Seek to Reduce Your Disability Benefit

Attorney Stephen JessupAuthor: Attorney Stephen Jessup

Have you received a mysterious letter from Aetna with The Rawlings Company LCC emblazoned across the top?

We recently received letters on Aetna letterhead, referencing our clients’ claims for disability, which start with: “Aetna Disability administers disability benefits under the group plan sponsored by your employer. We are requesting your cooperation in providing some additional detailed information about your claim, because we believe it may be the result of an accident or injury for which a third party (another person, organization, or insurer) may have some liability.

So what does this mean? To put it simply Aetna is trying to find creative ways to say you may owe them money!

Offsets and Other Income

If you are on claim for long term disability benefits under an ERISA governed group long term disability policy chances are your policy allows the insurance company to reduce your benefits for “Other Income.” The most common example, and maybe one you have experienced, is Social Security disability. Essentially, if “someone” is paying you money for your disabling condition, the insurance company is going to reduce their obligation to you and possibly request a repayment of a prior overpayment.

Another lesser known example of “Other Income” is the proceeds of any settlement or judgment resulting from the actions of a third party that contributed to your disability. For instance, if you were involved in a motor vehicle accident and because of your injuries you filed for disability under your employer’s disability policy and you receive settlement proceeds or a judgment at trial, your insurance carrier could be entitled to repayment of the money already paid out to you.

The Rawlings Company LLC

Pursuant to their website, The Rawlings Group is the “recognized leader in healthcare subrogation services field.” On the main page of their website they boast: “MAXIMUM RECOVERIES FROM THE INDUSTRY EXPERT for the services we provide, The Rawlings Group has an unbeaten record of recovering more money for more health plans than any other vendor.” (Subrogation is the legal doctrine whereby one person takes over the rights or remedies of another against a third party)

A simple search in Google reveals not so flattering information from individual insureds claiming to have been harassed by The Rawlings Group, medical procedures not being covered and vague implied threats of unknown proceedings.

What’s this mean for you?

Honestly, we are not quite sure yet. For one client in which we received the Aetna/Rawlings Company letter, the nature of the disability stems from a cancerous tumor from over 5 years ago. Hardly a case that might be the result of the actions of a third party! This leads us to believe that maybe this is a shot-in-the-dark form letter being sent by Aetna to see if there is a way for them to further lessen their financial obligation to provide you benefits under your group disability policy.

The disability attorneys of Dell and Schaefer quickly sought clarification as to the nature of these letters as we did not feel comfortable having our clients sign what we consider overly broad authorizations allowing some a company that is not mentioned anywhere in the plan documents, to collect whatever information they want. To date we have not received any response from Aetna as to our inquiries.

If you have received a letter from Aetna with indications of The Rawlings Company wanting to investigate your claim, please feel free to contact Attorneys Dell and Schaefer.

There are 24 opinions so far. Add your comment now.

Amy Vierra:

I received a letter from The Rawlings Group on behalf of my insurance company HealthNet. They indicated “that HealthNet recently processed a claim for the patient (me) listed above. According to your HealthNet contract, when a member is injured through the act of another person and is entitle to recovery from a third party, Health Net is entitle to reimbursement if the member receives any recovery for the medical expenses”, etc.

The strange thing is, I have never heard of and have never received an EOB for the dr. referenced in this letter. I did have a trip to the ER on the date referenced, but it was for an infected tooth and I have already paid the doctor that I received a bill from and an EOB from. What do you think is going on here?

Attorney Stephen Jessup:

Amy,

As indicated in the post, Rawlings Group is a subrogation company that has apparently been hired by HealthNet to recover payment from another source for some alleged treatment received. I would recommend you contact HealthNet to inquire as to the reason for the letter and to inform them that you have never treated with the doctor they referenced.

Sara:

I have received an “audit” from Aetna and Rawlings Company asking me for Newborn information, date of birth, address, and my current coverage carriers and phone numbers. I no longer have Aetna coverage (it ended 9-30-12, and I did have a baby during that time, 8/12).

Am I legally obligated to provide this information considering I haven’t had aetna insurance for over a year? I’m not going to just hand over my personal information unless I have to!

Attorney Stephen Jessup:

Sara,

It appears that they are contacting you with respect to a health insurance matter that I would presume has already been paid by Aetna. I would suggest contacting Aetna in writing to determine why you are receiving the notice. I did just that with respect to my client’s long term disability claim and never heard another word from Rawlings.

Nate:

Our 1 year old son fell down some steps and had an ambulance trip to the hospital. I have since received a subrogation form to complete. It was an accident, pure and simple. I’m concerned they will go after the home owners to recoup expenses. What should I do?

Attorney Stephen Jessup:

Nate,

I would advise you to contact a personal injury attorney as this is stemming from an accident as opposed to a disability claim.

Xcamote:

My daughter fell of her scooter on a public sidewalk. The reason was due to extremely uneven lifted pavement, it happened at night where street lights where not working and it was difficult to see. I went to the emergency room, everything went through normally, but now I’m receiving letters from Rawlings requesting the settlement amount from the city before they can come up with a figure of what I owe. I ask them over the phone what I owe them and they tell me they cant disclose that until I report my settlement amount. I haven’t filed a claim with the city yet because they are asking me for medical debts I incurred but Rawlings won’t tell me. Can they do that? Sounds suspicious to me.

Attorney Stephen Jessup:

Xcamote,

You will need to consult with a personal injury attorney as to your rights. Our experience with Rawlings Company, as noted in the article is purely with respect to claims for disability insurance benefits.

Michael M.:

I recently sought pain relief in the form of a cortisone shot in my right elbow for an injury I received 16 years ago related to a fall from a tractor trailer I was legally employed to work on. I also sought a 2nd medical opinion from the same orthopedic surgeon during the same visit for an old dislocating shoulder injury from 7 years ago to which I had an MRI done at the doctors request. Neither one of these injuries had anything to do with Aetna at the time they occurred. Now I am being harassed by the Rawlings Company and I would very much like that to stop ASAP. I receive monthly letters from Rawlings with a threatening tone if I do not respond. I wish the HIPA laws could be leveraged against Aetna for sharing our information to a 3rd party company without our consent. I’m sure there is fine print on some Aetna document I signed that may or may not have contained the word “subrogation”. At the time I signed Aenta’s agreement forms I had no idea what that word even meant.

Attorney Stephen Jessup:

Michael,

Is Aetna your long term disability carrier or health insurance carrier?

Randy:

I also received numerous letters from The Rawlings Company (TRC) asking me to provide them with what I consider to be private, personal information. With all the scams going on today I didn’t respond, as I felt if it was legitimate then Aetna would be contacting me themselves about this and not some second-rate collector of sorts. I constantly receive bogus letters and emails from such people all claiming I “have” to provide them with this or that, so naturally I thought TRC was just another scammer among many. Aetna is my primary health provider but I am disabled with a progressive neurological disease and because of this my clarity of thought isn’t what it used to be, and with all the scams among us anymore I felt this was just another attempt to get personal info. Since my initial “survey” I have received a total of FIVE surveys all claiming that I HAVE to release my info to them, and in simple terms, if I don’t give them whatever they want it will constitute failure to comply with Aetna under the terms of my plan. I have received other similarly worded threats like this over the years from scam outfits so I was hesitant to even contact them about this because it’s difficult for me to speak anymore. Why hasn’t Aetna at least informed their client base they’re using some third-party money collector of sorts (TRC) and that it’s okay to deal with them? Just performing a simple internet search of these people doesn’t paint a very appealing picture so why would I be inclined to release my information to them when even Aetna hasn’t informed me of their partnership with them?

Attorney Stephen Jessup:

Randy,

I would agree with you and seek confirmation from Aetna that Rawlings is in fact an authorized representative of the company as it relates to your claim.

Michael M.:

Hi Stephen,

Aetna is my primary (only) health insurance carrier. Unlike Randy in the last post, I have received confirmation that Rawlings is authorised to represent Aetna. However I did not solicit the services of Rawlings and I feel threatened by Rawlings as I am not comfortable with this process.

Attorney Stephen Jessup:

Michael,

I would discuss your concerns with an Aetna representative. Rawlings sole purpose is to see if someone else is liable for payment of services. If they find said source it saves Aetna money.

Michael M.:

I understand what you’re saying Stephen and I have already had that discussion with my Aetna representative. I am not interested in protecting Aetna’s interests. I pay for their service. I do not expect to have Aetna share my private information with a 3rd party “collection agency” on behalf of Aetna for Aetna. Nor do I intend to cooperate with Rawlings. Regardless of who is liable. In my case no one is liable for my injuries so they would not need to worry in the first place. All they did was upset me when I learned what the subrogation process is. I am sadly disappointed that the US government does not protect ordinary citizens from the invasive nature of subrogation. I guess I don’t understand how the HIPAA laws are supposed to protect people because both Aetna and Rawlings have obviously found a successful way to challenge it or they would not be harassing people like they do.

Josefine:

Hi Stephen,

I recently received a letter from the rawlings company asking me to fill out their questionnaire. I had an accident (slip and fall) two years ago and won the injury claim ($300.000). Last year, I signed up with Aetna and then this year I had another surgery done that had to do with my accident from two years ago. Now I got the letter from Rawlings. Do you think if I fill it out and tell them about winning my injury claim I will have to pay Aetna back for this recent surgery? Can they do that? Aetna pre-authorized the surgery. Thank you.

Attorney Stephen Jessup:

Josefine,

I am not sure how your health insurance policy reads but there may be some right to subrogation by Aetna. I would suggest you review your health insurance policy and possibly contact Aetna for clarification.

Brendan S.:

I am getting harassed by Rawlings Company LLC. What happens if I just ignore them?

Susan H.:

Hi, I am insured with Aetna through my husband, and I am on Social Security Disability. Now, the husband has been getting letters from Rawlings saying that Aetna Traditional periodically requires info from our members to update our records and ensure accurate claim payments.

I do not feel comfortable in giving my Medicare ID#, which is my SS# and if I’m receiving SS benefits (I do not have Part B, just Part A) as it’s not of their business. What are my options at this point? Would appreciate any suggestions. Thank you.

Attorney Stephen Jessup:

Susan,

Aetna does use Rawlings to investigate claims to determine if there is a right for subrogation under the policy (if someone else is responsible for your disability that may have to cover part of the cost). I appreciate your concerns and would recommend that you contact Aetna in writing to vocalize same to verify if in fact they have hired Rawlings to perform any activity as it relates the Aetna claim.

Brittany M.:

I received this letter and filled out the questionnaire online. Oops! I had a hemorrhagic stroke due to an AVM bursting and I have been going to rehab for months to recuperate… then I received this letter. I checked the ongoing illness box but I have also applied for a critical illness stroke claim. Is there a chance that they will want that money paid back to Aetna when I had no injury or accident?

Attorney Stephen Jessup:

Brittany,

Is your Aetna policy of disability or health insurance benefits?

Netlace:

I have received three request from Rawlings for gathering key information for Cigna. My husband talked with Cigna and they said they do not use this company. They said discard it. I am concerned because after a search there are many with this same thing. This is something that needs looked into. Is this not fraud? It is signed Sincerely Cigna.

Attorney Stephen Jessup:

Netlace,

If Cigna has advised you that they have not authorized Rawlings to work on their behalf then I would not communicate with them. You may also want to file a complaint with your state insurance commissioner on account of Rawling’s actions.

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