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Lawsuit leads to government healthcare investigation


Sometimes, civil litigation may have serious and lasting consequences that go beyond finances or business. A breach of contract and bad faith lawsuit filed by a college student concerning his medical treatment against Aetna Insurance led to an investigation by California's insurance commissioner. The student claimed that Aetna denied coverage for infusion of intravenous immunoglobulin for the treatment of his immune disorder. Depositions during this lawsuit's discovery period instigated the commissioner's inquiry.

Aetna's former medical director admitted under oath that he never looked at the patient's records when deciding whether to approve or reject care. He claimed that he followed Aetna's training and procedures. These supposedly consisted of nurses reviewing records and making recommendations. Furthermore, he also acknowledged that he did not know about the student's condition or appropriate treatment. The physician further testified that he was unaware of the medical outcome if this treatment was discontinued. He served as director of Aetna in Southern California from March of 2012 to February of 2015.

The insurance commissioner said that the state is investigating the extent of this practice and it would be concerning if the insurer made coverage decisions without a physician reviewing medical records. He also claimed that this practice could be illegal. He said any insured individuals who may have been impacted by this practice should contact the commission.

Aetna, the nation's largest health insurer, is defending this physician. According to its statement, Aetna will explain its clinical review process during the state's investigation. Aetna's medical directors take their medical professionals' responsibilities seriously and they work collaboratively with nurses whose opinions and recommendations are part of the decision-making process, according to its statement.

Individuals can suffer many serious and long-term consequences when other parties do not meet their obligations under an insurance policy or other contact. An attorney can help assure that these responsibilities are met or that an injured party can seek damages or compensation.

Source: Fortune, "Aetna under investigation after former exec admits denying care without reading patient's records," Natasha Bach, Feb. 12, 2018

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