$4.8M Aetna, Optum ERISA Settlement Seeks Preliminary Approval from Court [UPDATE]

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A $4.8 million settlement has been reached that, if approved by the court, will resolve a proposed class action lawsuit over the allegedly unlawful administrative fee Aetna Inc. and Aetna Life Insurance Co. charged for certain chiropractic and physical therapy services performed by OptumHealth Care Solutions’ network of providers.

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The proposed class action settlement, which awaits preliminary approval from United States District Judge Martin Reidinger, aims to cover a class of all participants or beneficiaries of ERISA health insurance plans insured or administered by Aetna for whom coinsurance responsibility for a claim was assessed using an agreed rate between Optum and Aetna that exceeded the provider’s contracted rate with Optum for the treatment provided.

The settlement also seeks to cover participants or beneficiaries of self-insured ERISA health insurance plans administered by Aetna for which plan responsibility for a claim was assessed using a rate above the provider’s contracted rate with Optum for the treatment provided.

According to settlement documents, the challenged arrangement applied to Optum providers in North Carolina, South Carolina, Georgia, Virginia, Illinois, Indiana, and the District of Columbia.

If the $4,800,000 deal is approved, class members will not need to do anything to receive an Aetna and Optum settlement payment, the agreement says.

According to court documents filed on February 27, 2025, half of the settlement fund—which consists of a $4.6 million payment from Aetna and a $200,000 contribution from Optum—will be used to compensate affected plan members for their alleged overpayments, and the other half will be used to compensate affected health care plans.

Cash payout amounts will be pro-rated based on how much an individual or health plan overpaid for covered Optum provider services between July 12, 2012 and the date the settlement goes into effect, the plaintiff’s memo relays.

Per the settlement agreement, final payment amounts for plan members who received covered services between July 12, 2012 and December 31, 2017 will be calculated based on Aetna’s records.

Plan members whose claims include dates of service after 2017 will need to submit supplemental information showing that their Aetna plan document at the time—that is, the summary plan description—did not disclose that the allowed amount could include an administrative fee. If no documentation is submitted, the plan member’s final payment amount will not include pre-2017 services, court documents state.

According to the agreement, individual claims—i.e., the total amount that a plan member overpaid for covered services—will be capped at $5,000 “for purposes of calculating the share of distribution.”

Payments to health plans will be calculated based on the total amount of challenged fees each plan paid for covered services for its members, the settlement agreement says. Rebates from the deal will be issued to the plans directly should the settlement be approved, the document adds.

The plaintiff’s memo anticipates that, if the deal is okayed, individuals will receive “most of their alleged overpayments,” while health plans will recover a “material percentage.”

The document also relays that in situations where an individual would receive a settlement payout of less than $15, or a plan would recover less than $500, no payment will be issued.

If the deal is approved, notice of the settlement will be sent to eligible class members within 60 days of the approval date, court documents share. Class members can get more information about the deal once the official settlement website, AetnaAdminFeeSettlement.com, is established.

ClassAction.org will update this page if and when the official Aetna and Optum settlement website goes live.

The lawsuit against Aetna and Optum, initially filed in June 2015, claimed the companies violated the federal Employee Retirement Income Security Act (ERISA) and the terms of Aetna’s ERISA health care plans by improperly assessing administrative fees for covered chiropractic and physical therapy services performed by providers in Optum’s network. The class action suit contended that the companies misrepresented and misclassified the administrative fee as a medical expense and unlawfully collected it from Aetna health care plans and plan members.

The contractual arrangement between Aetna and Optum under which the ERISA lawsuit’s allegations arose ended around April 1, 2023, the settlement agreement states. Aetna represents that it is no longer processing new claims using the challenged Aetna-Optum rate at issue, court documents say.

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