On our blog, we frequently discuss the improper tactics insurers use to deny legitimate claims for life, health, disability and other forms of insurance. For our latest article on the pervasive problem in health insurance claims denials, see https://mslawllp.com/la-times-report-pervasive-problem-of-improper-health-insurance-denials/. Mckennon Law Group PC has had much experience litigating against health insurers who deny legitimate medical claims. We know this is a rampant problem. So, it was not shocking to us that at least one very large health insurer, Aetna, took highly improper actions to deny medical insurance claims.

On February 12, 2018, the California Department of Insurance (“CDI”) issued a press release confirming its investigation of Aetna, one of the largest health insurance providers in the U.S. California Insurance Commissioner Dave Jones directed an investigation into Aetna’s claims handling practices for potential misconduct. Specifically, Aetna’s determinations to deny coverage without a physician’s review of the medical records. The Commissioner expressed his concern over Aetna’s reviewing practices as follows:

I have directed the California Department of Insurance to open an investigation of allegations regarding Aetna’s practices in denying claims and requests for prior authorization for care. The department is also investigating Aetna’s utilization review process. If a health insurer is making decisions to deny coverage without a physician ever reviewing medical records that is a significant concern and could be a violation of the law. The department is seeking more information from Aetna about their claims denial process and I would encourage any Californians who are concerned that they might have been affected to contact the California Department of Insurance at 1-800-927-4357.

CDI’s announcement follows from a report on the topic by CNN, focusing on several troubling admissions made by Aetna’s former medical director for southern California, Dr. Jay Ken Iinuma. Reportedly, Dr. Iinuma admitted that he did not review patients’ medical records firsthand. As a matter of practice, he instead relied on nurses’ secondhand reporting of pertinent information in the medical records.

These admissions appear during the former medical director’s video-taped deposition in an ongoing lawsuit for breach of insurance contract and bad faith. In the lawsuit, Plaintiff Gillen Washington alleges that his health insurer, Aetna, improperly denied preauthorization coverage of his monthly infusion of intravenous immunoglobulin, an otherwise regular treatment for his rare immune disorder. Although Dr. Iinuma authorized the denial as not medically necessary, the deposition transcript revealed his limited knowledge of Washington’s rare disease and its necessary treatment.

Whereas CNN described Dr. Iinuma’s admissions as “stunning,” the use of underqualified consultants to support a denial of coverage is more common than some might think. At the McKennon Law Group PC, we frequently see improper claims denials supported in this manner, through a nurse consultant’s review of the medical records and not a physician’s review of the same. Even more shocking, the insurer often relies on the unqualified consultant’s opinion over that of the insured’s treating physician. We regularly see this in the handling of long-term disability insurance claims, short-term disability insurance claims and health insurance claims.

Similarly, an insurer may attempt to support an improper denial of coverage by using a non-specialist physician. This can be problematic in instances like the above because, as Dr. Iinuma also admitted in his deposition, he had little experience treating those with the rare immunological disorder Washington suffers from, and thus, he knew little about its necessary treatment. We can also surmise that the Aetna nurse who had reviewed his medical records also had little experience treating those with immunological disorders. Yet, he still authorized denial of coverage for the treatment as not medically necessary. More troubling still, lurking behind these issues of qualification are issues of bias. Often, the unqualified consultants work on-site, essentially acting as employees of the insurer, which in turn, renders them more likely to provide an opinion in favor of a claim denial.

Having an experienced long-term disability, individual disability, health and life insurance attorney matters to the success of your insurance claim, particularly where the denial of coverage relies on the opinion of an unqualified consultant or non-specialist peer review physician. If your claim for health, life, short-term disability or long-term disability insurance has been denied, call (949)387-9595 for a free consultation with the attorneys of the McKennon Law Group PC, several of whom previously represented insurance companies and are exceptionally experienced in handling ERISA and Non-ERISA disability and medical insurance claims.