Aetna, one of the largest insurance companies in Missouri, agreed to pay $4.5 million in fines for violations of state law that include paying for elective abortions and failing to cover certain autism benefits.

A 1983 Missouri law prevents insurers from covering elective abortions unless an individual has purchased a separate policy, known as a rider, to cover the procedure.

Riders contain premium costs in addition to what people pay in premiums for their comprehensive health-care coverage. Aetna, according to the settlement document, paid for nine elective abortions in cases where the insured did not purchase a separate abortion rider, as mandated by Missouri law.

The settlement document also outlines Aetna’s violation of a 2010 law that mandates insurance companies pay for certain autism treatments. Aetna is reviewing claims of those potentially affected and the company will pay for those claims that were incorrectly denied at 9 percent interest, according to the settlement agreement.

Under the terms of the agreement, the Missouri Department of Insurance will monitor the insurer for three years. Should no other issues occur during that period and so long as Aetna complies with all the terms of the settlement agreement, the company will not lose its state license. During the monitoring period, though, the Department of Insurance can stop Aetna from conducting business in Missouri for up to a year if the company continues to violate state insurance regulations.

The department agreed to waive $1.5 million of the $4.5 million fine if Aetna fully complies with state law and the settlement agreement during the monitoring period.

Gov. Jay Nixon (D) announced the agreement, reportedly the largest against an insurance company in Missouri.

“When an insurance company chooses to do business in our state, they agree to follow our laws,” Nixon said in a statement. “These were serious violations that deserved serious punishment—and that’s what Aetna received.”

This is reportedly the second time Aetna has been fined for violating Missouri law. In 2012, the state recovered $1.5 million in fines for similar claims that Aetna violated state laws on insurance coverage for abortions, contraceptives, and autism treatments.