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National insurer once again in news for wrong reasons

On Behalf of | Mar 5, 2018 | Denied Insurance Claims

Message to Aetna principals: You seriously might want to give some thought about injecting greater rationality and fairness into your insurance claim review process.

We last spotlighted Aetna — one of the nation’s largest insurance providers — in our February 12 blog entry. We noted therein the stunning news that the company’s former medical head routinely denied policyholders’ claims over many years without ever once consulting with doctors. He admittedly relied solely on nurses’ input and, moreover, rarely spoke with them.

His admissions, we noted, are now having “tsunami-like repercussions in the medical industry and bringing withering scrutiny from regulators.”

And now there’s this. A federal judge overseeing a denied disability claim charging Aetna with bad faith recently remanded the claim to Aetna for reconsideration after finding the company’s conduct unreasonable and lacking evidence to support it.

Once again, the matter centrally involved a nurse’s input, with a registered RN — not a doctor — initially denying the policyholder’s disability claim. Aetna sought a referral opinion, which, notably, was delivered by the same nurse. Predictably, it yielded the same result.

The claim on appeal also went nowhere, with a doctor enlisted by Aetna concluding that, despite contrary evidence, the claimant ( a woman whose physician stated she could no longer work) was not disabled.

The claimant brought the matter to court, where the judge found the MD’s opinion to be without merit for its lack of any real analysis or independent investigation. In remanding, the court noted Aetna’s failure to give the policyholder “a full and fair review.”