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Aetna under investigation for denying care without appropriate review of medical records

Written by Diane Archer

Several states are investigating Aetna, the nation’s third largest health insurance company, for denying care without appropriate review of medical records. CNN reports that a former Aetna medical director testified under oath that he never looked at patients’ medical records when determining whether to approve or deny a claim. The former medical director’s testimony speaks volumes about the failings of our commercial health insurance system.

In the case of a California patient needing treatment for a rare immune disorder, Aetna’s former medical director testified in a deposition that he relied exclusively on nurses’ notes to decide not to approve medical care. The patient is suing Aetna for breach of contract and bad faith.

Aetna has pushed back, claiming that its former medical director did review parts of the patient’s medical records and that his testimony was taken out of context. But, the former medical director failed to even acknowledge the value of having a medical doctor review medical records before deciding whether to deny what could be a life-saving treatment. Moreover, what is perhaps most troubling in this case, is that Aetna’s protocols appear not to require its medical director to have training on a particular condition or to speak to a specialist with training on that condition before deciding whether to deny coverage.

The former medical director testified that he knew almost nothing about the patient’s condition and how he might be affected if he were denied coverage for his treatment. The former medical director was clearly not equipped to make a determination on treatment even had he reviewed the patient’s medical records.

California’s insurance commissioner, on seeing Aetna’s former medical director’s deposition testimony, said that Aetna may have violated the law. In certain instances, he said, Aetna’s medical director should be reviewing patients’ medical records, not nurses.  It is not clear where the California insurance commissioner stands on the propriety of a medical director making a coverage determination about a life-saving treatment for a condition about which he knows little, without first seeking advice from a specialist with expertise on the condition.

The California Department of Insurance is investigating Aetna.  Colorado, Washington and Connecticut are also investigating Aetna’s medical review practices.

Aetna has more than 23 million subscribers and is in the midst of being acquired by CVS.

Here’s more from Just Care:



  • Aetna, United Healthcare, Humana, Cigna, Anthem and the rest of the for profit health insurance companies are all motivated by profits for their stock holders that include their directors who in addition to receiving outrageous salaries also receive stock in their own companies. The biggest problem with the PPACA is that it puts our nation’s healthcare in the hands of these thieves who care not a wit about the health of their policy holders. People worry that single payer would put medical decisions in the hands of government bureaucrats but do they really prefer that these decisions be left to the tender mercies of private for profit insurance companies?

    • Agreed, and good point!

      Do you remember the JFK speech in which he said, “Ask not what your country can do for you; ask what you can do for your country”? This line is a good example of why Presidents hire speechwriters: to make tired old ideas sound new, fresh, and valid.

      The truth is the the “country” is ultimately the citizens who live in it. A government that doesn’t serve its citizens—all of them—doesn’t have any real reason to exist.

      That this country has failed to provide universal health care to all citizens is a moral failure of the highest degree. We spend trillions on defending against virtually nonexistent threats to our well-being (does anyone really believe that goatherders in the mountains of Afghanistan were poised to attack us here in the US?) and completely ignore the far more realistic threats posed by disease, pollution, mental health issues, assault rifles, and so on.

      Ultimately, democracy and capitalism are fundamentally incompatible: either we organize society on the basis of “one citizen, one vote” or on the basis of “one dollar, one vote.” We’ve already tried the latter, and it hasn’t worked—ever.

      Time to try something different.

  • This is not only Aetna, but it is every private insurance company in the country. I have dealt with private insurance twice in the past 35 years for injuries that lasted doe more than 6 months, and the same thing happened both times. The insurance company paid for everything for 6 months, and then the legal battles began. I am still fighting with my insurance company over 2 knee injuries that happened in 2005. The insurance company paid for everything for 6 months, and they haven’t paid a penny since. I was forced onto SSA Disability in 2008. These injuries were fully documented with MRI’s right from the begging and there has never been any reason for the insurance company to contest the injuries. The insurance company sent my MRI’s to an IME, [Independent Medical Examiner] and the IME wrote the entire evaluation backwards saying 5 times that my MRI’s were wrong, and 5 times that the medical reports were confusing, and he wasn’t sure which knee he was reporting on. In 2005 I had surgery on my left knee, but when I tried to get surgery performed on my right knee in 2006, the insurance company denied all responsibility for the injury. This denial of surgery resulted in the total loss of my right knee, and this has caused an alignment problem that affects my right ankle and hip. I started out with a right knee that could have been repaired, but now I have entire right leg going out, and this has been documented with follow up MRI’s. Many of the legal battles have nothing to do with the injury, but are the result of too many insurance companies, and too many types of insurance. The legal battles are over Where it happened, How it happened, When it happened, and is it a Preexisting condition. THE SOLUTION: Make Medicare a single payer system and standardize on salaries. With a single system, it would not make any difference of Where it happened, How it happened, When it happened, or is it a Preexisting condition, since the same party would have to pay for the injury.

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