California Investigating Aetna Over its Medical Director Reviews of Recordsmary

We found an interesting story by CNN regarding Aetna Insurance.

Apparently, California’s Insurance Commission has commenced an investigation into Aetna and its health insurance practices. The Commissioner learned that a former Medical Director for Aetna recently admitted under oath (in a deposition) that it was his practice to never actually review a patient’s medical records when deciding whether to approve or deny a medical procedure.

This deposition was taken in a health insurance denial claim. The deposition came as part of a lawsuit filed against Aetna by an individual suffering from a rare immune disorder which required infusion of intravenous immunoglobulin (IVIG), which can be quite expensive (anywhere from $20,000-$30,000 in our experience). This physician admitted that he never reviews the medical records when asked to make a decision about approving a claim for treatment. Rather, the doctor in question simply reviewed the nurse’s workup of the file and his or her summary.

Our law office has long suspected that Aetna, and other insurers, engage in similar practices in the context of deciding whether to approve a long-term disability insurance claim. We have handled many cases which involve suspicious reviews by doctors working directly for an LTD insurance carrier or physicians hired as “independent consultants” for a separate company that provides these vendor services to disability insurers. At times, an LTD insurer may request reviews by more than one physician. We have often seen that the medical records summary section of these reviewing physicians’ reports to be highly similar if not identical, suggesting that these summaries have been prepared by another individual, and not the actual doctor who has signed the report.

The long-term disability attorneys at McDermott Law always seek out the reason behind an insurer’s denial of long-term disability benefits. The search often leads us to question the veracity and accuracy of the insurance company’s reviewing physicians’ opinions. There are hundreds of such physicians performing peer review or records reviews of pending long-term disability claims who earn substantial income in doing so. The financial motivations underlining this arrangement need to be explored in every case. Getting to the bottom line and truly understanding these arrangements can of course be difficult. We are often amazed at how difficult it can be to convince a judge to allow us to pursue “discovery” into these issues despite the admissions of medical reviewers in cases that they have not performed an actual evaluation of the claimant nor ever spoken with him or her. Perhaps the admission of this particular Aetna employee-doctor will help convince judges that insurers frequently cut corners in the processing of claims and that the opinions of the retained peer reviewers are not at all objective or, the case of this doctor, allegedly fraudulent.

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