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Aetna under investigation after exec admits to denying care without reviewing patient records

A former medical director at Aetna, the third-largest health insurance provider in the United States, admitted under oath that he approved and denied patient’s care without reviewing their medical records. According to reports by CNN and Fortune magazine, California Insurance Commissioner Dave Jones is now investigating Dr. Jay Ken Iinuma. Jones said of the investigation:

“If the health insurer is making decisions to deny coverage without a physician actually ever reviewing medical records, that’s of significant concern to me as insurance commissioner in California—and potentially a violation of law.”

Dr. Iinuma was deposed in a  lawsuit against Aetna. The lawsuit, filed by Gillen Washington, claimed breach of contract and bad faith when the insurer denied him coverage for an intravenous immunoglobulin infusion. Washington, a student, has an immune disorder, and he believed the infusion was necessary for treatment.

During his testimony, Iinuma indicated that Aetna’s training stipulated that nurses were the ones who would review the patient’s files and would then give doctors recommendations. He said that he was merely following Aetna’s training, and admitted that he did not know about Washington’s condition, its appropriate treatment, or what the result of denying the treatment would be for the patient.

Aetna released a statement saying that the company “look[s] forward to explaining our clinical review process.” The insurance company has over 23 million subscribers all across the nation, and Dr. Iinuma personally served as a medical director for the company in Southern California from March 2012 to February 2015.

The lawyers of Spiros Law, P.C. are following this story closely and will keep you updated on any new developments in the investigation. Before dealing directly with an insurance company who may not be looking out for your best interest contact us at (815) 929-9292 to schedule a confidential consultation with our team today.