Aetna (US insurance) being sued by patient denied care by Medical Director who NEVER read file

[Gingergrrl]

From CNN:

https://www.cnn.com/2018/02/11/health/aetna-california-investigation/index.html

California's insurance commissioner has launched an investigation into Aetna after learning a former medical director for the insurer admitted under oath he never looked at patients' records when deciding whether to approve or deny care.

The California probe centers on a deposition by Dr. Jay Ken Iinuma, who served as medical director for Aetna for Southern California from March 2012 to February 2015, according to the insurer.

Jones said his expectation would be "that physicians would be reviewing treatment authorization requests," and that it's troubling that "during the entire course of time he was employed at Aetna, he never once looked at patients' medical records himself." "It's hard to imagine that in that entire course in time, there weren't any cases in which a decision about the denial of coverage ought to have been made by someone trained as a physician, as opposed to some other licensed professional," Jones told CNN.

The insurance commissioner said Californians who believe they may have been adversely affected by Aetna's decisions should contact his office.

The deposition by Aetna's former medical director came as part of a lawsuit filed against Aetna by a college student who suffers from a rare immune disorder. The case is expected to go to trial later this week in California Superior Court. Gillen Washington, 23, is suing Aetna for breach of contract and bad faith, saying he was denied coverage for an infusion of intravenous immunoglobulin (IVIG) when he was 19. His suit alleges Aetna's "reckless withholding of benefits almost killed him."

Washington's suit counters that Aetna ignored his treating physician, who appealed on his behalf months before his hospitalization that the treatment was medically necessary "to prevent acute and long-term problems." "Aetna is blaming me for what happened," Washington told CNN. "I'll just be honest, it's infuriating to me. I want Aetna to be made to change."

During his videotaped deposition in October 2016, Iinuma -- who signed the pre-authorization denial -- said he never read Washington's medical records and knew next to nothing about his disorder. (CVID or Common Variable Immune Deficiency). Questioned about Washington's condition, Iinuma said he wasn't sure what the drug of choice would be for people who suffer from his condition. Iinuma further says he's not sure what the symptoms are for the disorder or what might happen if treatment is suddenly stopped for a patient. "Do I know what happens?" the doctor said. "Again, I'm not sure. ... I don't treat it." Iinuma said he never looked at a patient's medical records while at Aetna.

Glovsky told CNN he had "never heard such explosive testimony in two decades of deposing insurance company review doctors."

Aetna defended Iinuma, who is no longer with the company, saying in its legal brief that he relied on his "years of experience" as a trained physician in making his decision about Washington's treatment and that he was following Aetna's Clinical Policy Bulletin appropriately.

Dr. Arthur Caplan, founding director of the division of medical ethics at New York University Langone Medical Center, described Iinuma's testimony as "a huge admission of fundamental immorality." "People desperate for care expect at least a fair review by the payer. This reeks of indifference to patients," Caplan said, adding the testimony shows there "needs to be more transparency and accountability" from private, for-profit insurers in making these decisions.

"If he has not looked at medical records or engaged the prescribing physician in a conversation -- and decisions were made without that input -- then yeah, you'd have to question every single case he reviewed." Murphy said when he and other doctors seek a much-needed treatment for a patient, they expect the medical director of an insurance company to have considered every possible factor when deciding on the best option for care.

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Aetna is not my insurer but I am sick to death of this BS from ALL of these private insurance companies who charge exorbitant amounts for monthly premiums but then deny even the most basic care. You are led to believe that a doctor reviewed your case and determined it to not be medically necessary but this scandal proves that doctors are not reviewing cases (as I suspected). I want to believe this will lead to positive changes but I doubt it b/c the entire system is corrupt to it's core.

 

[SueJohnPat]

This is outrageous, but from my own experience with Cigna’s ( or UNUM) long term disability does not surprise me at all. California is one of the more progressive states and have fined Cigna heavily. Thanks for posting this.