You don’t see this level of candor very often.

Gillen Washington, a 23 year old California man, sued AETNA after the insurer denied coverage for life saving infusions that Washington needed for treatment of common variable immune deficiency(CVID). In the course of litigation, Dr. Jay Ken Iinuma, the former Medical Director for Aetna, was whistled in for a deposition.

In that deposition, Iinuma admitted that he never looked at patient medical records when deciding whether to approve or deny care. Iinuma explained that he was simply following Aetna protocol, which called for nurses to review the medical records and then make recommendations to him. To make matters worse, Iinuma admitted that he had virtually no knowledge or understanding about CVID. Iinuma also admitted he wasn’t knowledgeable about what drugs were necessary to treat CVID or what would happen to patients once the drug treatments were discontinued.

Not surprisingly, Iinuma’s testimony caught the eye of Dave Jones, the California Insurance Commissioner. Jones is now reviewing Aetna’s conduct while Iinuma served as Medical Director from 2012-2015.

A disturbing revelation but hardly unique. Years ago I represented a young woman who, along with her fiancee, applied for life insurance from a large insurance company. Not long after their marriage the husband was diagnosed with a very rare and aggressive cancer that killed him in a matter of months. When his wife sought to collect on the life insurance policy, her claim was denied. The carrier had poured over the husband’s medical records and uncovered a doctor visit where he was complaining of a routine stomach ache. The stomach ache was treated and it resolved. The carrier insisted that the stomach ache could have been a symptom of the cancer and should have been explicitly disclosed during the application process. The failure to do so, in the insurer’s view, amounted to fraud.

My firm sued the carrier on behalf of the wife. During the deposition phase, it became apparent the decision to deny the claim was made arbitrarily by a low level underwriter who had absolutely no medical background or training. The underwriter admitted that she had no basis for the denial, apart from her hunch that routine stomach ache was cancer. Not long thereafter, the carrier indicated they were very much interested in settlement.