New revelations that a medical director of a major insurance company, Aetna, with over 20 million subscribers, never looked at patients' records before denying or approving care. That's leading to questions about Aetna's practices nationwide.
This all came to light last night when a video surfaced of Dr. Jay Ken Iinuma, a former medical director at Aetna, speaking in a deposition. He's the man who had the power to say "yes" or "no" to coverage for medical procedures. So... how did he make those decisions?
Well, it wasn't by looking at medical records, and now the state of California is investigating.
"If a health insurer is making decisions to deny coverage without a physician actually reviewing medical records, that's of significant concern to me as insurance commissioner in California," said California Insurance Commissioner Dave Jones, "and potentially a violation of law."
Dr. Iinuma's admission is part of a lawsuit by a young man named Gillen Washington, who has a serious immune deficiency.
Aetna initially paid for Washington's treatments, but in 2014, Iinuma didn't pre-approve payment for him to have infusions because they said they needed current blood work to meet the criteria. Despite being told more than once by his own doctor that he needed to come in for the blood work, he failed to do so for several months.
Without treatment, Washington became sicker and sicker, ending up in the ICU with a collapsed lung.
"The doctor said I had zero immunity. None. So that's terrifying," Washington said."
Now, a jury is expected to sort out the facts.
Among the questions: can an insurance company make decisions about a patient without looking at his medical record?
In a deposition, the doctor said he relied on info from nurses, who did read the records, and that he followed Aetna's policies.
Aetna, also responding, telling CNN their medical directors are trained to review all available medical information, including medical records, to make an informed decision... adding that medical directors "take their duties and responsibilities as medical professionals incredibly seriously."
California's insurance commissioner this morning is asking anyone who had a similar experience to come forward.