You would think it would be safe to assume that your insurance company would review your medical records before denying coverage for a medical procedure. However, that may not always be the case.
In a recent article published in Forbes magazine and reported by CNN, former Aetna Medical Director, Dr. Jay Ken Iinuma, testified under oath that he "never looked at patients' records when deciding whether to appove or deny care."
This admission was made during a deposition in a lawsuit filed against Aetna by Gillen Washington, a 23 year old with common variable immune deficiency (CVID) who was denied coverage for an infusion of intravenous immunoglobulin (IVIG) four years ago.
California’s insurance commissioner, Dave Jones, is now looking into Aetna’s relevant protocols.
As reported by CNN, Iinuma said in his deposition that, "he was following Aetna's training, in which nurses reviewed records and made recommendations to him."
In this particular case, Iinuma admitted that he had minimal if any knowledge of the medical condition, common variable immune deficiency (CVID), that Washington suffered from. He was also not clear about what the most effective drug would be to treat the patient’s condition, the symptoms of CVID, or even the consequences of the abrupt discontinuation of therapy for the condition.
Further, when asked by Washington's attorney if it was his general practice to look at medical records as part of his decision making process, he replied that it was not.
This opens up the obvious question of just how transparent health insurers are being with the public regarding their process for approval or denial of coverage, especially for complex medical care and procedures.
In Aetna’s response to CNN’s inquiry, the company said, “we look forward to explaining our clinical review process.”
While time will tell whether or not the lawsuit will be successful, the attorneys at Theodoros & Rooth will be curious to see the outcome. We stand by people who have been mislead or not given fair consideration when dealing with medical personnel and they certainly should be able to trust their own insurance company.
If you believe that you have been treated unfairly and suffered injury at the hands of your doctor or other medical professional, we want to hear about it. There is never a charge for your initial consultation at Theodoros & Rooth.