Health, Government - California Targets Insurance Company
California has launched an investigation of a health insurance company after a former director admitted he never researched a patient's medical records before denying that person health care.
"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," said California Insurance Commissioner Dave Jones.
The investigation revolved around on a deposition by Dr. Jay Ken Iinuma, who was medical director for Aetna, the nation's third-largest insurance provider with 23.1 million customers. It came in a lawsuit filed by 23-year old Gillen Washington who accuses Aetna of breach of contract and bad faith for denying him coverage for an infusion of intravenous immunoglobulin (IVIG) when he was 19. Mr. Gillen claims that Aetna's "reckless withholding of benefits almost killed him."
Iinuma said nearly all of his work was conducted online via email or messaging. Once in a while - not even once per month - he might place a phone call to the nurse for more details. Iinuma says this is the way the Fortune 500 health care provider trained him to handle such insurance claims, and Aetna he did his work according to company guidelines.
Physicians were astounded that their recommended courses of treatment for patients were stopped by people with lesser medical training to protect profit margins.