The Nation’s Third-Largest Insurance Provider Is In Big Trouble With The State Of California

The Nation’s Third-Largest Insurance Provider Is In Big Trouble With The State Of California

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A major insurance provider is under fire in California after a stunning deposition from its medical director about how the company handles its claims.

CNN reports that the California insurance commissioner has launched an investigation into Aetna after the company’s former medical director admitted under oath that he never looked at patients’ medical records before deciding whether to approve or deny care.

The ills of for-profit health care have long been dealt with by the American public. The revelation from Dr. Jay Ken Linuma, who served as medical director of Aetna in Southern California from March 2012 to February 2015, is a stunning and yet simultaneously unsurprising insight into the inner workings of such an insurance provider.

“It’s hard to imagine that in that entire course of time, there weren’t any cases in which a decision about the denial of coverage ought to have been made my someone trained as a physician, as opposed to some other licensed professional.” – California insurance commissioner Doug Jones to CNN

The news and the subsequent investigation could easily change the way that insurers are required to handle claims in the United States. Denial of coverage can quite literally lead to death in some cases, not to mention the fact that most other developed nations already provide access to health care as a basic right of citizenship. That for-profit health care is dysfunctional is known fact. It’s the personal consequences that remain largely invisible.

CNN reports that Gillen Washington, 23, is currently suing Aetna for breach of contract and bad faith. He says she was denied coverage for an infusion of intravenous immunoglobulin (IVIG) when he was 19. The lawsuit alleges Aetna’s “reckless withholding of benefits that almost killed him.”

Here’s how the testimony went during Linuma’s deposition in October 2016 at Washington’s trial:

“Do I know what happens? Again, I’m not sure…I don’t treat it, said Linuma when questioned about the symptoms are for Washington’s common variable immunodeficiency.

“Did you ever look at the records?” asked Washington’s attorney.

“No, I did not,” answered Linuma, who signed the pre-authorization denial for Washington’s treatment.

Aetna is the nation’s third-largest insurance provider and deals with 23.1 million customers. Jones said this about the case:

“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 the law.”


Featured Image via Montgomery County Planning Commission/Flickr/Public Domain