Aetna Under Investigation After Former Exec Admits Denying Care Without Reading Patient’s Records

February 12, 2018, 12:03 PM UTC

California is investigating Aetna, the nation’s third largest health insurance provider, after a former medical director at the company admitted under oath that he never looked at patients’ records when deciding whether to approve or deny care.

First reported by CNN, Dr. Jay Ken Iinuma is now under investigation by California’s insurance commissioner Dave Jones.

After CNN showed Jones a transcript of Iinuma’s testimony, Jones told the broadcaster that his office is investigating the extent of this practice. “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,” Jones said.

Iinuma’s deposition is part of a lawsuit against Aetna (AET) filed by a college student who is claiming breach of contract and bad faith. The student, Gillen Washington, was denied coverage for an infusion of intravenous immunoglobulin, a treatment for an immune disorder from which he suffers.

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Iinuma claimed that he was following his training provided by Aetna, in which nurses reviewed the records and gave him recommendations. He further admitted that he did not know about the condition nor its appropriate treatment, or even what would happen if Washington’s treatment was discontinued. Aetna has defended Iinuma.

In regards to the investigation, Aetna said in a statement that it “look[s] forward to explaining our clinical review process.” While the insurer emphasized that its medical directors “take their duties and responsibilities as medical professionals incredibly seriously,” it noted that they “work collaboratively with our nurses” whose input is factored in to the “decision-making process.”

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Iinuma served as medical director for Aetna in Southern California from March 2012 to February 2015. The insurance provider has 23.1 million customers across the country. Commissioner Jones said Californians who believe they may have been adversely affected by the insurer’s decisions should contact his office.

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