Several news outlets are reporting that California’s insurance commissioner has launched an investigation into Aetna after its former medical director admitted that he did not review patient records when making a decision to deny coverage for various medical procedures. CNN’s article about this shocking revelation and emerging scandal can be found here. The revelation came in a deposition in an insurance lawsuit arising under California law in Superior Court in Orange County, California. For those of us who represent participants in health and disability benefit plans, Dr. Jay Ken Iinuma’s admission that he did not review patient records in making medical necessity determinations is additional confirmation that many health insurance plans and disability benefit plans repeatedly, routinely, and wrongfully deny claims for benefits in violation of applicable laws and regulations.
All employee benefits plans covered by the Employee Retirement Income Security Act of 1974 (“ERISA”), including health insurance and disability benefits plans, are required to provide plan participants with a full and fair review of their claims for benefits. Likewise, individual health insurance policies that are not covered by ERISA are required to provide their participants with a full and fair review of their claim. In order to receive a full and fair review, an insurer’s claims personnel, including their medical directors, must review the participant’s relevant medical records before making a decision. Far too often, it is clear when a client’s claim has been denied that the insurer has failed to provide the claimant with a full and fair review of his or her claim.
If you believe your health claim or long term disability benefit claim has been wrongly denied, you should contact an experienced ERISA employee benefits lawyer or insurance lawyer without delay. Your right to appeal the denial will be subject to certain time limitations. At The Garner Firm, your initial consultation is always free. Contact us today, for your free consultation.