After learning from CNN that a former medical director for Aetna said in a deposition that he never looked at patients' records when deciding whether to approve or deny care, instead relying on nurses to review the records and make recommendations to him, California Insurance Commissioner Dave Jones has launched an investigation.
In a statement, Commissioner Jones said, "I have directed the California Department of Insurance to open an investigation of allegations regarding Aetna's practices in denying claims and requests for prior authorization for care. The department is also investigating Aetna's utilization review process. If a health insurer is making decisions to deny coverage without a physician ever reviewing medical records that is a significant concern and could be a violation of the law. The department is seeking more information from Aetna about their claims denial process and I would encourage any Californians who are concerned that they might have been affected to contact the California Department of Insurance."
In its report, CNN said that the deposition of the former Aetna medical director, Dr. Jay Ken Iinuma, took place in a lawsuit brought against Aetna by Gillen Washington for breach of contract and bad faith; Mr. Washington alleged that Aetna had improperly denied him coverage for an infusion of intravenous immunoglobulin.
Aetna issued the following statement in response to the CNN report:
Aetna medical directors review all necessary available medical information for cases that they are asked to evaluate. That is how they are trained, as physicians and as Aetna employees. In fact, adherence to those guidelines, which are based on health outcomes and not financial considerations, is an integral part of their yearly review process.
While we can't comment on the alleged actions of a former employee due to ongoing litigation, we want to be clear that our policies always have our members' best interests in mind.
With regard to Mr. Washington, it's important to note that Aetna has paid for each and every intravenous immunoglobulin treatment received since he first submitted a claim under his health plan in 2014. Mr. Washington remains an Aetna member today, and we continue to pay for his treatments.