Knowledge Center

On March 12, 2026, a federal court in New Jersey allowed a putative class action lawsuit against Aetna to move forward. The case was brought on behalf of Aetna plan members and focuses on claims that Aetna did not pay to out-of-network providers according to the terms of its own plans.

What Is the Lawsuit About?

The lawsuit alleges that Aetna failed to reimburse providers at the agreed-upon rates under its National Advantage Program (NAP).

NAP is a program where out-of-network providers agree to discounted rates through third-party network vendors such as MultiPlan and similar organizations.

Aetna’s Motion to Dismiss

Aetna asked the court to dismiss the case, arguing that the lawsuit did not clearly point to plan language requiring those payments.

Court’s Findings

The court disagreed.

The court found that the plans include clear, mandatory language stating that when services are provided by a NAP provider, a pre-negotiated rate “will be paid,” and that NAP defines how the allowed amount is calculated.

The court concluded that these plan provisions operate in mandatory terms and plausibly establish that Aetna was required to pay providers at the negotiated NAP rate.

The court also found that the plaintiffs therefore alleged a legally enforceable right to benefits.

Based on these findings, the court allowed the case to proceed.

Highlights of the Decision

The decision notes that insurers often use payment methods that reduce reimbursements below agreed-upon network rates.

The decision also states that both patients and providers can rely on plan language to enforce proper payment and challenge systematic underpayments under ERISA.

Key Points from the Case

• The lawsuit alleges underpayment of claims tied to NAP agreements
• The court identified mandatory plan language regarding reimbursement
• The court found that the plaintiffs alleged a legally enforceable right to benefits
• The case will proceed

About the Case

The plaintiffs are represented by Cohen Howard LLP and Berger Montague.