The medical director's statement may be sufficient for the state to find fault with how this particular claim was handled, he says, even if there is no problem with Aetna's overall policies and procedures.
"If that is what happened, it's probably a technical violation of Aetna's internal policy and the requirements of most states," Trembowicz says. "I would see this as pretty atypical. Insurance companies keep records of all appeals and decisions, including the physician who signed off on it, and their electronic records indicate whether the physician accessed the relevant documents. I don't think this situation is common at Aetna or with any other insurer."
Trembowicz notes that the media attention to this case plays into the hands of critics who allege health plans deny legitimate claims for financial reasons.
Another insurer, Anthem, has been criticized for its policy in some states denying coverage for emergency department claims when the complaint turns out not to be a true emergency, and the Aetna dispute adds fuel to that fire, he notes.
"None of this is good for Aetna or other health plans. If people are reading the news and seeing that claims are denied and the physician reviewer doesn't even look at the medical record on appeal, that's a terrible impression for Aetna," he says. "But on the facts of this case, it may be far less egregious than it appears at first."
In a February 14 hearing about this lawsuit, Orange County Judge John C. Gastelum said that the accounts in the media presented "clearly a totally one-sided story."
Aetna issued a statement clarifying that "medical records were in fact an integral part of the clinical review process" for the disputed claim and included a sworn statement from the doctor saying, "In addition to reviewing the relevant portions of submitted medical records, it was also generally my practice to review Aetna nurses' summaries, notes, and the applicable Aetna Clinical Policy Bulletins."
Gregory A. Freeman is a contributing writer for HealthLeaders.