California Probes Aetna Over Report Saying Claim Denial Practice

PALO ALTO, CA – The insurance commissioner in California wants to know how often Aetna's medical directors reject claims without first reviewing medical records. That's according to CNN, which first aired a report stating a former medical director for the insurer did just that.

The network said the former medical director had testified under oath that in his three years as medical director for Aetna for Southern California "he never once looked at patients' medical records himself."

CNN says that the doctor said he made his decisions based on recommendations from nurses.

In a statement, Aetna says that while they can't comment on the specific allegations of the former employee, "Aetna medical directors review all necessary available medical information for cases that they are asked to evaluate. That is how they are trained, as physicians and as Aetna employees.

"In fact, adherence to those guidelines, which are based on health outcomes and not financial considerations, is an integral part of their yearly review process."

CNN quotes California Insurance Commissioner David Jones saying, "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.

"That's why we've contacted Aetna and asked that they provide us information about how they are making these claims decisions and why we've opened this investigation."

File photo of Aetna via Jessica Hill/AP Photo.