Former Aetna medical director admits to not reviewing patient records; investigation launched

Posted at 3:56 AM, Feb 12, 2018
and last updated 2018-02-12 03:56:29-05

(CNN) – California’s insurance commissioner is asking patients to step forward if they feel they were wronged by Aetna after the company’s former medical director said under oath he never looked at patients’ records before approving or denying care.

During a deposition, Dr. Jay Ken Iinuma, who served as medical director for Aetna for Southern California from March 2012 to February 2015, said he was following Aetna’s training, in which nurses reviewed records and made recommendations to him.

Iinuma said nearly all of his work was conducted online. Around once a month, he said, he might place a phone call to a nurse for more details.

The acknowledgment by Iinuma is a cornerstone for a lawsuit against the insurance giant by a 23-year-old man named Gillen Washington.

Aetna initially paid for Washington’s infusions of intravenous immunoglobulin, which he needed because of a serious immune deficiency, but in 2014, Iinuma didn’t pre-approve payment.

Aetna didn’t pre-authorize the treatment because it said it needed current blood work to meet the criteria, and despite being told more than once by his own doctor that he needed to come in for the blood work, Washington failed to do so for several months.

Without treatment, Washington became sicker and sicker, ending up in the intensive care unit with a collapsed lung.

During his videotaped deposition in October 2016, Iinuma said he never read Washington's medical records and knew next to nothing about his disorder.

The case is expected to go to trial later this week in California Superior Court, where a jury will sort out the facts.

Among the questions to consider: Can a doctor at an insurance company make decisions about a patient without looking at his medical record?

“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.

Patient advocates have long been concerned that insurance companies don’t take the time to thoroughly review patients’ medical records before making decisions.

Responding to the investigation, an Aetna spokesman told CNN that the company’s medical directors are “trained to review all available medical information – including medical records – to make an informed decision.

The spokesman added the directors “take their duties and responsibilities as medical professionals incredibly seriously.”

Copyright 2018 CNN, Attorney Scott Glovsky, Getty Images, Gillen Washington. All rights reserved.