Common use of Rescission of Coverage Clause in Contracts

Rescission of Coverage. Aetna may rescind the covered person’s coverage if the covered person, or the person seeking coverage on the covered person’s behalf: • Performs an act, practice or omission that constitutes fraud; or • Makes an intentional misrepresentation of material fact. The covered person will be given 30 days advance written notice of any rescission of coverage. As to medical. pediatric dental, pediatric vision care, and prescription drug coverage only, the covered person has the right to an internal appeal with Aetna and/or the right to a third party review conducted by an independent External Review Organization if the covered person’s coverage under this Policy is rescinded retroactive to its Effective Date. Certain services, such as inpatient stays, certain tests, procedures, outpatient surgery, therapies and equipment, and prescribed medications require precertification by Aetna. Precertification is a process that helps the covered person and their physician determine whether the services being recommended are covered medical expenses under the plan. It also allows Aetna to help the covered person’s provider coordinate the covered person’s transition from an inpatient setting to an outpatient setting (called discharge planning), and to register the covered person for specialized programs or case management when appropriate. Precertification is not the same requirement as a plan’s Referral Requirement. A plan’s referral requirement and process is separate from the plan’s precertification requirement and process. Refer to the Schedule of Benefits for the plan’s Referral Requirement. The plan’s Referral Requirement must be followed in addition to the plan precertification process. The covered person does need to precertify services provided by a non-preferred care provider. Preferred care providers will be responsible for obtaining necessary precertification for the covered person. Since precertification is the provider’s responsibility, there is no additional out-of-pocket cost to the covered person as a result of a preferred care provider's failure to precertify services. When a covered person goes to a non-preferred care provider it is the covered person’s responsibility to obtain precertification from Aetna for any services, treatments, procedures, visits or supplies on the precertification list below. If the covered person does not precertify, benefits may be reduced. The list of services requiring precertification appears later in this section. If the covered person’s outpatient hospice care has been precertified, and the covered person subsequently requires a hospital stay for pain control or acute symptom management, that hospital stay does not have to be precertified.