Aetna lawsuits and settlements in 2025 and 2026 span Medicare billing fraud, kickback allegations, algorithmic claim denials, fertility coverage discrimination, spinal surgery denials, and mental health parity violations. The largest by dollar value is a $117.7 million False Claims Act settlement with the U.S. Department of Justice announced in March 2026, but several class actions affecting members directly are still moving through final approval, with reimbursement deadlines and eligibility windows worth checking now.
The $117.7 Million Medicare Advantage Fraud Settlement
On March 11, 2026, the Department of Justice announced that Aetna agreed to pay $117.7 million to resolve allegations that it submitted inaccurate diagnosis codes to the Centers for Medicare and Medicaid Services to inflate risk-adjustment payments under Medicare Advantage.1U.S. Department of Justice. Aetna Agrees to Pay $117.7 Million to Resolve False Claims Act Allegations Aetna did not admit liability.2HHS Office of Inspector General. Aetna Agrees to Pay $117.7 Million to Resolve False Claims Act Allegations
The bulk of the settlement, $106.2 million, involved Aetna’s 2015 chart review program. According to the government, Aetna hired coders to review patient records for diagnosis codes it could submit for higher payments. When those reviews also turned up previously reported codes that were not actually supported by the records, Aetna kept the money and failed to delete or withdraw the unsupported codes, then certified to CMS that its data was accurate.3Healthcare Finance News. Aetna to Pay $117.7 Million in Risk Adjustment Settlement
The remaining $11.5 million came from a whistleblower suit filed by Mary Melette Thomas, a former Aetna risk-adjustment coding auditor. Thomas alleged that from 2018 through 2023, Aetna submitted or failed to withdraw inaccurate diagnosis codes for morbid obesity, including codes assigned to patients whose recorded Body Mass Index did not support that diagnosis. She received $2,012,500 for bringing the case.3Healthcare Finance News. Aetna to Pay $117.7 Million in Risk Adjustment Settlement
Aetna declined to enter into a Corporate Integrity Agreement with the HHS Office of Inspector General, the compliance-monitoring arrangement that usually accompanies large healthcare fraud settlements. In response, OIG reserved the right to exclude Aetna from federal healthcare programs and said Aetna would face heightened scrutiny for 10 years using alternative monitoring tools.4HHS Office of Inspector General. Aetna Corporate Integrity Agreement
Medicare Advantage Broker Kickback and Disability Discrimination Case
Aetna is a defendant in an active DOJ lawsuit, United States ex rel. Shea v. eHealth, et al. (No. 21-cv-11777), filed in the U.S. District Court for the District of Massachusetts in 2021, with the DOJ intervening in 2025. The suit names Aetna alongside Elevance Health and Humana, plus brokers GoHealth, SelectQuote, and eHealth. The government alleges that between 2016 and 2021 the insurers paid brokers to steer beneficiaries toward their plans, and that Aetna and Humana conspired with brokers to discriminate against disabled beneficiaries they viewed as less profitable, threatening to withhold payments unless brokers enrolled fewer disabled individuals.5U.S. Department of Justice. United States Files False Claims Act Complaint Against Three National Health Insurance Companies
On March 25, 2026, a federal judge denied the defendants’ motion to dismiss the kickback and discrimination claims. A separate unjust enrichment claim was dismissed on the ground that the False Claims Act already provided a sufficient path for recovery.6Becker’s Payer Issues. Judge Rules Aetna, Elevance, Humana Must Face Medicare Kickback Allegations
AI-Driven Claim Denials
Aetna’s parent, CVS Health, was one of three Medicare Advantage insurers targeted in an October 17, 2024 report by the Senate Permanent Subcommittee on Investigations, which alleged that CVS, UnitedHealthcare, and Humana used algorithmic tools to sharply increase denials of post-acute care between 2019 and 2022. The report cited a CVS “Post-Acute Analytics” project launched in 2021 that projected $77.3 million in savings from denied care.7Healthcare Dive. Medicare Advantage AI Denials Senate Report As of 2022, the three insurers together denied about 25 percent of all post-acute care coverage requests for their Medicare Advantage enrollees.8STAT News. Medicare Advantage Insurers AI Technology Prior Authorization Claims Denials Senate Investigation
A class action has also been filed against Aetna alleging it used AI to improperly deny post-acute care to Medicare Advantage patients, sidestepping medical professional review. CVS has said that while it uses AI for workflow automation, “all prior authorization decisions are ultimately made by qualified medical professionals.”9Brief Glance. Aetna Accused of Using AI to Deny Medicare Claims
The same allegations fueled a securities suit, Louisiana Sheriffs’ Pension and Relief Fund v. CVS Health Corporation (No. 1:24-cv-05303, S.D.N.Y.), in which investors accuse CVS executives of concealing the use of cost-driven denial algorithms. CVS filed a motion to dismiss that remained pending as of mid-2025.10Bernstein Litowitz Berger & Grossmann LLP. CVS Health/Aetna Securities Litigation
Peters v. Aetna: Dummy Code Settlement for Chiropractic and Physical Therapy Claims
If you received chiropractic or physical therapy services through an Aetna plan after July 12, 2012, you may be part of the Peters v. Aetna Inc., et al. (No. 15-cv-00109, W.D.N.C.) settlement class of more than 250,000 members.11Healthcare Dive. Aetna Optum Dummy Codes Settlement The suit alleged Aetna and OptumHealth Care Solutions used “dummy” service codes so that an administrative fee Optum charged for processing certain claims was billed as a medical expense, inflating what plan members and their health plans paid.12Aetna Optum Admin Fee Settlement. Long Form Class Settlement Notice
Chief Judge Martin Reidinger granted final approval on September 4, 2025. The total settlement value was about $8.35 million. Aetna put $4.6 million and Optum $200,000 into a compensation fund for patients and health plans, and Aetna paid $3.55 million in attorneys’ fees separately.13Bloomberg Law. Aetna, Optum Cleared for $8.35 Million Dummy Code Settlement
LGBTQ+ Fertility Coverage Settlements
Two class actions challenged Aetna’s requirement that members complete a period of “unprotected heterosexual sexual intercourse” without conception, or pay out of pocket for six to twelve cycles of artificial insemination, before qualifying for fertility benefits.14National Women’s Law Center. Settlement Reached With Aetna Over LGBTQ Fertility Coverage
Goidel v. Aetna
Filed in September 2021 in the Southern District of New York, Goidel v. Aetna received final approval on October 14, 2025.15National Women’s Law Center. NWLC Lawsuit: Emma Goidel v. Aetna The settlement covered roughly 143 class members, most entitled to a minimum payment of about $12,300, with room for additional reimbursement. Aetna also agreed to make intrauterine insemination a standard medical benefit for all members and to revise its artificial insemination and IVF requirements to improve LGBTQ+ access.16Emery Celli Brinckerhoff Abady Ward & Maazel LLP. Final Approval Settlement in Groundbreaking Case for LGBTQ Families Fertility Treatment Coverage
Berton v. Aetna
A second suit, Berton v. Aetna (No. 4:23-cv-01849-HSG, N.D. Cal.), extends equitable fertility coverage to LGBTQ+ Aetna members nationwide. Lead plaintiff Mara Berton alleged $45,000 in out-of-pocket fertility costs that would have been covered had she been in a heterosexual relationship.17CalMatters. Aetna Lawsuit LGBTQ IVF Fertility U.S. District Judge Haywood Gilliam Jr. granted preliminary approval in late 2025. Class members can receive up to $10,000 individually if the class numbers 175 or fewer, or a pro-rata share of a $1.75 million fund if larger. A separate $250,000 fund is available to members who can show additional financial harm.18California Infertility Settlement. Berton v. Aetna Settlement The final approval hearing is set for June 5, 2026.19Claim Depot. L-ADR Surgery Settlement
Lumbar Artificial Disc Replacement Settlement
For years, Aetna classified single-level lumbar artificial disc replacement surgery as experimental and investigational and denied coverage. Two consolidated cases in the Central District of California, Hendricks v. Aetna Life Insurance Co. (filed August 2019) and Howard v. Aetna Life Insurance Co. (filed March 2022), challenged those denials; the Hendricks class was certified in June 2021.20WorkCompAcademy. Aetna Resolves SoCal Denial of Disc Surgery Class Action
Aetna revised its policy in February 2023 to cover the procedure as medically necessary under certain criteria, but the case continued for patients already denied. A settlement in principle was reached on May 16, 2025, with a preliminary approval motion filed in October 2025. Class members who paid out of pocket for the surgery can be reimbursed up to $55,000, and current Aetna members can be authorized for future procedures based on their surgeon’s attestation of medical necessity, bypassing Aetna’s internal review.21Becker’s Spine Review. Aetna to Pay $55K to Some Spine Patients in Settlement A $2.56 million fund covers administrative costs and attorneys’ fees, with reimbursement payments handled separately by Aetna. Final approval was set for June 5, 2026.19Claim Depot. L-ADR Surgery Settlement
Pennsylvania Mental Health Parity Fine
In January 2026, the Pennsylvania Insurance Department fined Aetna $550,000 under a consent order following a market conduct examination covering October 2021 through December 2022. The department identified multiple mental health parity violations, including incorrect analysis and application of benefit limits for behavioral health services.22Pennsylvania Governor’s Office. Shapiro Admin Protects Consumers, Fines Aetna for Violation of Mental Health Parity Laws
Regulators found delays in processing claims, missing delay notification letters, improper denials tied to poor internal communication about prior authorizations, and incomplete claims files for autism spectrum disorder services. Aetna also failed to clearly communicate cost-sharing for applied behavior analysis.23Becker’s Behavioral Health. Aetna Fined $550K for Mental Health Parity Violations
Under the consent order, Aetna must reprocess improperly handled claims and pay members what they are owed with interest, reprocess claims that failed parity requirements, improve internal systems, update benefit documents on cost-sharing, and revise denial letters for autism-related services. Most corrective actions must be finished within 12 months.22Pennsylvania Governor’s Office. Shapiro Admin Protects Consumers, Fines Aetna for Violation of Mental Health Parity Laws If you had a behavioral health claim delayed or denied by Aetna in Pennsylvania during the examination period, watch for reprocessing notices from the company.