California Insurer Under Strong Scrutiny for Claim Denials

Aetna has had better weeks.

In fact, it’s likely that the country’s third largest insurer — and issuer of many health and long-term private disability policies to Californians — has never before endured criticism to the degree it now faces in the wake of recent news developments.

A deposition from late 2016 is at the core of what has rapidly become a company public-relations nightmare. It features taped comments from Dr. Jay Ken Iinuma, Aetna’s former medical director, over a multi-year span.

What Iinuma revealed has flatly shocked legions of providers, regulators and medical industry commentators across the country. He stated that he routinely denied care claims without ever consulting with doctors or even examining patients’ records. Moreover, he only checked with nurses offering opinions on approve-versus-deny matters, and “zero to one” times per month on average.

Iinuma’s comments have resonated across the country like a grenade blast. Prominent doctors, medical professors and others allege bad faith in Aetna claim denials underlain by a claim review process that is illusory, unlawful and potentially deadly for patients.

One prominent physician commenting on Iinuma’s statement that he never once even scanned a medical record in a case where he denied coverage calls that admission “incredible.” Another said he was “shocked” and “flabbergasted” by it.

Some painful reckoning may be on the way. The California insurance commissioner says that his department will now systematically peruse every Aetna claim that was denied during Iinuma’s tenure as medical director.

Experienced LTD attorneys who advocate solely and forcefully on behalf of policyholders note with interest — but not stark surprise — an insurer’s admission of what is clearly bad-faith conduct in the claim-denial process.

We make an additional point at the established LTD insurance law firm of Roboostoff & Kalkin in San Francisco concerning policyholders who are treated unlawfully by private insurers.

That is this: Such individuals have many rights that parties insured under ERISA-governed plans lack when seeking a meaningful legal remedy. Those include the right to a jury trial, the potential to receive additional damages for emotional distress, and in certain instances, punitive damages.

When you pay for a disability policy and dutifully comply with its terms, your insurer has a reciprocal duty to act in good faith. When it doesn’t, a proven legal team can advocate aggressively for you and seek maximum compensation on your claim.