The California Department of Insurance is now examining Aetna’s claims denial process after a former medical director for the insurer’s Southern California operations, Jay Ken Iinuma, MD, said under oath that he never looked at a patient’s health record when deciding whether to approve a deny a claim.
Iinuma said he was following Aetna’s training to review recommendations from nurses who had read the patient’s record, rather looking at the record himself. California Insurance Commissioner Dave Jones said his office has asked Aetna to provide more information about its clinical review process.
"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," he told CNN.
The information came out as part of Iinuma’s deposition in a lawsuit filed against Aetna by a college student with a rare immune disorder. 23-year-old Gillen Washington has accused Aetna of “almost killing him” by denying coverage for an infusion of intravenous immunoglobulin (IVIG) when he was 19, while the insurer countered that Washington ignored their request for new blood work before authorizing the treatments.
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