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Dawson and Rosenthal
Dawson and Rosenthal

California to investigate Aetna’s insurance claims process

The insurance commissioner of California is currently investigating the insurance provider Aetna regarding statements made by the company’s former medical director. In a recent deposition, the medical director stated that in all his time at Aetna, he never looked at clients’ medical records when he was assessing whether to approve or deny care. It is possible that many clients’ insurance claims were denied because their medical records were not properly assessed by a physician.

Dr. Jay Ken Linuma, the medical director for Aetna for Southern California from 2012-2015, admitted in under oath that instead of examining his patients’ medical records himself, his nurses would review the records and make recommendations to him. Dr. Linuma claimed that he was following Aetna’s internal practices for its claims process. The deposition was the result of a lawsuit brought by a former client whose benefits were withheld.

California Insurance Commissioner Dave Jones expressed his concern that the insurance provider may have denied coverage to its policyholders based on recommendations that were not made by a licensed physician. He also stated that the practice of denying coverage without having a physician review medical records may be a violation of California insurance law.

Insurance providers have an obligation to conduct a thorough investigation when assessing its clients’ claims. An insurer that neglects to properly investigate a claim is said to be acting in bad faith. Every state has laws addressing insurance providers who act in bad faith, and California is no exception. The state takes bad faith insurance very seriously, and there are frequently serious penalties for insurers that neglect their obligations to their consumers.

Aetna is currently the third-largest health insurance company in the United States, insuring over 23 million clients. A representative for the company stated that it looks forward to working with Commissioner Jones to address its clinical review process. The commissioner advises Aetna policyholders who believe that their claims decision was affected by this revelation to contact the California Department of Insurance.