Insurance Company Doctors Don’t Review Medical Records Before Denying Health Insurance Claims? Are You Kidding Me?

California Department of Insurance Commissioner Dave Jones has opened an investigation into allegations that health insurer, Aetna, denies insureds’ claims and requests for prior authorization for medical care without ever reviewing medical records. Although Aetna’s improper utilization review practices come as no surprise to the attorneys at our office, this revelation has sparked widespread, national media attention.

The allegations giving rise to Commissioner Jones’ investigation into Aetna’s claims handling practices come from videotaped deposition testimony of Dr. Jay Ken Iinuma who served as medical director for Aetna’s Southern California business operations between March 2012 and February 2015. During the deposition, Dr. Iinuma said he was following Aetna’s training when he never once looked at patients’ medical records himself before denying their claims for coverage.

Dr. Iinuma’s deposition was taken as part of a lawsuit filed by a college student, Gillen Washington, who was denied coverage for an infusion of intravenous immunoglobin (IVIG) when he was 19 to treat a rare auto-immune disorder.  Washington sued Aetna in Orange County Superior Court for breach of contract and bad faith, alleging that Aetna’s “reckless withholding of benefits almost killed him.”  Aetna initially paid for Washington’s treatments (each fusion can cost up to $20,000) but when Washington asked Aetna to pre-authorize a November 2014 infusion, Aetna said it was obligated to review Washington’s medical records.  Aetna claims that Washington’s treating provider failed to timely provide medical records in response to Aetna’s pre-authorization review.  Washington counters Aetna’s narrative of the events surrounding Washington’s ongoing requests and medical need for IVIG treatment.  However, it was during Dr. Iinuma’s deposition, where the real bombshell in the case was revealed. The former Aetna medical director testified that he never read Washington’s medical records and knew nothing about the disorder Washington was suffering from despite denying Washington’s pre-authorization request and signing the denial letter.  Dr. Iinuma further testified that most of his work was done online and he would rarely if ever consult with an Aetna nurse about a particular claim prior to denying it.

As a result of the national news coverage resulting from Dr. Iinuma’s stunning deposition testimony, Orange County Superior Court Judge John Gastelum postponed Washington’s jury trial over Aetna’s improper denial of IVIG treatment.  The trial date was originally set for February 2018 but has been continued to August 20, 2018.  We will keep you posted on the outcome of this suit.

For more on this story, check out the following links:

Dr. Iinuma’s Deposition Transcript: https://californiahealthline.files.wordpress.com/2018/02/jay-ken-iinuma.pdf

CNN Coverage of Aetna’s Utilization Review Practices: https://www.cnn.com/2018/02/11/health/aetna-california-investigation/index.html

Insurance Commissioner Dave Jones’ Statement Regarding the DOI’s Investigation of Aetna:  http://www.insurance.ca.gov/0400-news/0100-press-releases/2018/statement017-18.cfm

At Kantor & Kantor we have a team of experienced attorneys who are all dedicated to obtaining the best possible result for our clients. If you or someone you know are being denied health benefits by your insurer, please call Kantor & Kantor for a free consultation at 877-783-8686. We understand and we can help!

 

 

 

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