Aetna's former medical director says he never reviewed patient records before denying care

California's insurance commissioner is investigating Aetna after one of the health insurer's former medical directors admitted under oath he never reviewed patients' medical records when deciding whether to approve or deny claims, according to CNN.

Jay Iinuma, MD, who served as medical director for Aetna for Southern California from March 2012 through February 2015, said in a 2016 deposition he followed Aetna's training by relying on recommendations from nurses when deciding whether to approve or deny care.

California Insurance Commissioner Dave Jones expressed outrage after recently reading the deposition transcript.

"It's hard to imagine that in that entire course in time, there weren't any cases in which a decision about the denial of coverage ought to have been made by someone trained as a physician, as opposed to some other licensed professional," he told CNN. "That's why we've contacted Aetna and asked that they provide us information about how they are making these claims decisions and why we've opened this investigation."

Dr. Iinuma's deposition came as part of a lawsuit filed by a 23-year-old college student, Gillen Washington. Mr. Washington, who suffers from a rare immune disorder, sued Aetna for breach of contract and bad faith after Aetna refused to cover an infusion of intravenous immunoglobulin when he was 19. He claims Aetna's "reckless withholding of benefits almost killed him," according to CNN.

In response to CNN's questions, Aetna defended its practices and the coverage decision in Mr. Washington's case.

"Medical directors — and all of our clinicians — take their duties and responsibilities as medical professionals incredibly seriously," Aetna said in a statement to CNN. "Similar to most other clinical environments, our medical directors work collaboratively with our nurses who are involved in these cases and factor in their input as part of the decision-making process."

More articles on payer issues:

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UnitedHealthcare is using AI to personalize employer coverage: 3 things to know
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