A lawsuit alleging that the insurance company Aetna broke a contract has blown up into an investigation led by the California Department of Insurance. When CNN showed the transcript of a deposition taken from Aetna’s medical director in Southern California from March 2012 to February 2015 to the California Insurance Commissioner, he became alarmed when the medical director stated that he never looked at medical records when authorizing or denying medical care.
The commissioner has launched an investigation of Aetna’s denials of coverage or preauthorization during the time period when the specific medical director worked for the company. Investigators intend to focus on the appropriateness of each decision and whether the insurance company broke laws. State insurance codes authorize monetary penalties for violations.
The medical director’s testimony appeared to indicate that he made decisions without examining medical records. For the case in question, he said that he was not familiar with the disease or what would happen if he denied treatment. The lawsuit that revealed this information concerns a man who claims that he almost died because the insurer would not authorize an infusion of medicine.
When a person suspects that an insurance company has made an error or willfully avoided an obligation within a contract, an attorney might provide insights about how to respond to the problem. If a legal analysis of the insurance policy reveals that the person could have a legitimate complaint, an attorney may be able to prepare insurance litigation. This service might include assembling evidence, filing court papers and opening negotiations with the insurer. Potentially, an attorney may achieve a settlement prior to a trial, but if a trial becomes necessary, an attorney may be tasked with managing jury selection and presenting evidence of wrongdoing.