In a stunning admission, a former medical director for Aetna admitted, under oath, that he never looked at patients’ records when deciding whether to approve or deny care, according to an exclusive news report from CNN. Dr. Jay Ken Iinuma, who was medical director for Aetna from March 2012 – February 2015, made this admission during a deposition in an insurance coverage lawsuit.
Here’s the kicker: the doctor claims that he was following Aetna’s training, in which nurses reviewed records and made recommendations.
The Insurance Commissioner of California has announced an investigation, and according to the news report, is looking into how widespread the practice is within the insurance giant. Aetna is the nation’s third largest insurance provider and a giant in disability insurance policies.
On the Long Term Disability insurance side of Aetna’s business, their practices do not appear to be much better, as many cases are nurse reviewed cases. We wonder whether CNN can secure the deposition of any of the myriad of medical reviewers who work for Aetna on their Long Term Disability insurance business, or whether Dr. Iinuma also did work on the disability insurance portion of the business. As it is, many courts have chastised Aetna on its handling of group Long Term Disability insurance claims. Some courts have noted the cozy relationship it maintains with doctors who review medical records of claimants (never examining the patient when determining how disabled they might be). One court used colorful language in its description, noting how several of these reviewing doctors from Aetna have had their bread buttered multiple times by Aetna – in questioning their impartiality over their repeated utilization. See Maiden v. Aetna (2016).
Frankel & Newfield has had many disability insurance ERISA claims, appeals and litigations with and against Aetna, and other long term disability insurance companies, where it is clear that a medical doctor has either never reviewed the medical records of a claimant, or the review was done of only a select section of the medical records. This selective consideration of medical records is commonly seen and problematic, while the reliance upon nurse only medical, often dealing with complicated and complex, and often co-morbid medical issues, is often well beyond a nurse’s capacity, and is actually a violation of ERISA and the regulations which govern ERISA disability insurance claims.
Given the size of Aetna, and our experiences, we believe it is possible that the entire company works the same way: nurses or other non-doctors review paper files, write their own recommendations and send them to the medical directors for a rubber stamp denial.
Frankel & Newfield will not be surprised if a state insurance commission’s investigation reveals a massive, systemic practice of claim denials based on paper reviews that are not substantiated by a proper reviewing process by a doctor. We’ve seen too many claimants being denied when their medical records clearly indicate their inability to perform the tasks of their occupations.
However, until such time as the investigation is started, gets underway and is completed, could be many months. If you have had your Aetna long term disability insurance claim denied or terminated, call our office at 877-LTD-CLAIM (877-583-2524) to find out how we can help. Don’t wait for the California Insurance Commissioner to compete their investigation, because there are strict time limits on disability claim appeals. Do not lose your rights to pursue your claim.