Aetna settles with patient who sued for coverage denial

A little over a year ago, California’s insurance commissioner began investigating Aetna for possibly denying care coverage without reviewing the records of a patient who’d filed a lawsuit. Now the company has agreed to an out-of-court settlement.

The insurance giant’s trouble in this case started in 2016, when a 23-year-old man sued over a denial of coverage for infusion treatments he needed for a rare immune disorder.

Next, in February 2018, a former medical director of Aetna said during a videotaped deposition that he had not personally perused the patient’s medical records before deciding whether to approve or deny these insurance claims. Instead, he said, he relied on recommendations from nurses—and added that this practice was not unusual at Aetna.  

It was this latter admission, made under oath, that spurred the investigation.

CNN covered the settlement April 26, noting its terms were not disclosed and that Aetna is now a part of CVS.

“Given the importance of how benefits determinations are made by Aetna and other companies, I would hope we could get more transparency of their procedures,” a medical-ethics professor at NYU told CNN reporter Wayne Drash. “I thought it might come out of this case, but sadly it doesn’t appear so.”

The implication was that a desire to avoid full transparency may explain the company’s quiet settlement of a suit the grounds for which Aetna initially denied quite vehemently.

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