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Analysis

Aetna Quietly Settles High-Profile Lawsuit Over Denied Coverage

By John Commins  
   April 29, 2019

The health insurer had pledged a vigorous defense in the suit, but isn't saying what prompted the confidential settlement. 

Aetna has reached an out-of-court settlement in a high-profile lawsuit that was sparked when a physician for the health insurer said he'd never looked at a patient's health records before denying coverage.

Plaintiff Gillen Washington sued the health insurer in 2016 after he was denied coverage for a rare immune disorder, the infusion treatments for which can cost up to $20,000.

Former Aetna medical director Jay Ken IInuma, MD, stated in a deposition that he did not examine Washington's records before deciding whether to deny or approve care, relying instead on information provided by nurses who reviewed the records.

The California Department of Managed Health Care and the California Department of Insurance subsequently launched an investigation into Aetna's policies and procedures for approving or denying claims.

Aetna, which was acquired by CVS Health last November in a $70 million megamerger, did not immediately respond Monday morning to HealthLeaders' request for comment on the settlement, which was reached in late March, just ahead of a planned trial.

However, T.J. Crawford, vice president of external affairs for CVS Health, told CNN that the company doesn't "comment on legal settlements, which are commonplace and by no means an admission of wrongdoing."

Washington's attorney, Scott Glovsky, told CNN through a spokesman that "the matter has been resolved to the parties' mutual satisfaction."

Related: Related: California launches investigation following stunning admission by Aetna medical director

Related: Probes into Aetna's Claim Denials May Not Find Much

When the allegations were made public, Aetna said it would fight the suit.

"Our policies always have our members’ best interests in mind.  When those policies are called into question, we will defend them," the company said in a media release.

The insurer charged CNN with biased reporting, based on the allegations made by the plaintiffs, and said IInuma's words were taken out of context, and that his later explanation was ignored by much of the media.

It's not clear what prompted the health insurer to agree to a settlement. 

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.


KEY TAKEAWAYS

Plaintiff Gillen Washington sued the health insurer after he was denied coverage for a rare immune disorder, the infusion treatments for which can cost up to $20,000.

Former Aetna medical director Jay Ken IInuma, MD, stated in a deposition that he did not examine Washington's records before deciding whether to deny or approve care, relying instead on information provided by nurses.


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