California Insurance Commissioner Dave Jones has begun an investigation into the clinical review process at Aetna, a healthcare giant that currently provides insurance coverage for more than 23 million people. In a recent deposition, its former medical director for Southern California, Dr. Jay Ken Iinuma, admitted to never reviewing patient records when determining whether they would receive care.
According to recent reports, this admission has created grave concern about Aetna’s clinical review practices and whether they are, as Jones put it, “potentially a violation of law.”
Washington v. Aetna
This disturbing revelation about Aetna’s clinical review process came to light during a lawsuit filed against the company by 23-year-old Gillen Washington, a college student insured by Aetna and diagnosed with an immune disorder. After being covered by Kaiser, Washington started with Aetna in January 2014.
According to Washington, Aetna withheld coverage for necessary infusions, which typically cost tens of thousands of dollars, based on claims that Washington had not performed or submitted necessary bloodwork, despite his having submitted blood work 3 years prior.
In order to be approved for coverage for the infusion, Washington’s physician advised that he should come in for new blood work. Once his blood was tested, Aetna began covering the costs of his infusion. However, Washington asserts that Aetna behaved recklessly and ignored his physician’s appeals to the company, in which the physician claimed that the infusions were absolutely essential and must be covered in order to “prevent acute and long-term problems” for Washington.
Aetna Medical Director Admits to Never Looking at Medical Records
While under oath, Iinuma claims he acted according to company protocol when making decisions about Washington’s benefits and benefits for other patients during his time as medical director in Southern California. According to Iinuma, Aetna’s training instructs nurses to assess patients’ health records and make recommendations to the physician, in place of the medical director personally reviewing such records.
In regards to Washington’s case, Iinuma claims to have never reviewed his medical records, as part of Aetna protocol. Iinuma, who denied pre-authorization for Washington’s infusion, admits to never having read Washington’s records and knowing nothing about his disorder or how it should be treated.
When questioned by Washington’s attorney, Iinuma explicitly admits to relying exclusively on recommendations and prepared materials from nurses. When asked how many times he contacted a nurse for clarification or further information regarding a patient or condition, Iinuma answered, “Zero to one.”
As has been stated by Insurance Commissioner Dave Jones, these actions and this failure to review medical records when deciding to approve or deny coverage for important procedures are potentially unlawful. If Iinuma’s claims are true and his failure to review patient records is indicative of a greater problem within Aetna, this could have serious consequences for health insurance recipients in Southern California.
If You Are an Aetna Patient Who Has Been Denied Necessary Benefits, Seek Legal Representation for Your Bad Faith Insurance Claim Immediately
If you have been denied coverage from Aetna or have been denied coverage for necessary benefits (especially during Iinuma’s directorship, from March 2012 to February 2015), Delfino Green & Green can help you. We understand that you depend on your health insurance company for help, especially when it comes to necessary, costly treatments, and we are here to hold your insurer accountable when they fail to provide you with the conscientious, attentive review you deserve.
Our attorneys in San Francisco aren’t afraid to go up against your
health insurance company when their inefficiency or unethical practices threaten your health and well-being.
Get in touch with a member of our experienced legal team right away by calling 415-442-4646. You can also contact us online to tell us a little about your case and schedule your free consultation.
