Aetna Settles Claim Denial Lawsuit

By Consumers For Quality Care, on May 1, 2019

Aetna has settled a lawsuit that included testimony in which one of the company’s medical directors admitted to not reviewing consumers’ medical records before denying their claims. An investigation by California’s insurance commissioner, which Consumers for Quality Care has previously written about, followed CNN reporting on the medical director’s comments. At the time of the original reporting, Aetna defended its practices, according to CNN.

The Aetna medical director was recorded saying he did not review patient’s medical records in a deposition, after the insurer was sued by Gillen Washington. Washington sued the company for breach of contract and bad faith in 2015, after he was denied coverage for an infusion of intravenous immunoglobin (IVG). Washington describes Aetna’s behavior as “reckless” and says the denial almost killed him.

At the onset of the investigation, former Commissioner Dave Jones questioned the practice at hand.

Jones told CNN that he found it troubling “if the health insurer is making decisions to deny coverage without a physician actually ever reviewing medical records.”

“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,” Jones said.

Consumer advocates are disappointed by the settlement. Insurance coverage denials often impact consumers at their most vulnerable times. Denials can lead consumers to consider drastic measures to receive care. For example, an Alaskan woman considered quitting her job in order to be covered by Medicaid after her gastric bypass surgery was denied by the insurer. Advocates hoped that the investigation would help put public scrutiny on one of insurers’ more damaging practices. The director of medical ethics at New York University’s School of Medicine still hopes this day will come.

“Given the importance of how benefits determinations are made by Aetna and other companies, I would hope we could get more transparency of their procedures,” Caplan said. “I thought it might come out of this case, but sadly it doesn’t appear so.

The news of the settlement came as a surprise to members of the legal community. Doug Terry, an attorney who won a $25 million verdict from the insurer last year, says that the insurer does not settle cases easily. The terms of the settlement have not been announced.