The Battle with Insurance Companies to Obtain Prescriptions

The trouble is that Dr. Iinuma denied Mr. Washington’s appeal without having reviewed it. Mr. Washington sued Aetna for “reckless withholding of benefits,” and as part of the lawsuit, Dr. Iinuma was deposed. During the deposition, Dr. Iinuma admitted that he had never reviewed Mr. Washington’s records. He knew this because during his time as the medical director for Aetna, he had not reviewed any patient’s medical records. We apparently should not find this concerning, because he also admitted that he did not know anything about common variable immunodeficiency and did not know the consequences of stopping therapy.

With the system we have now, … [w]e learn to overdocument & undertreat, using regimens that we know are doomed to failure, because we must demonstrate that failure to gain access to the drugs that might actually help our patients.

The mind reels. We have all complained—privately and not so—about implacable insurance companies making arbitrary or ill-reasoned decisions, but I wonder how many of us suspected that these decisions were not reasoned at all. And yet, this seems like a natural extension of what we already knew to be true. Of all the times I have received a rejection of preapproval from an insurance company, I wonder how many times the undersigned recognized (or could even spell) granulomatosis with polyangiitis. Treating rheumatic diseases is challenging even for rheumatologists; it is difficult to imagine that every medical director of every insurance company is actually a peer.

Even if Dr. Iinuma had reviewed every page of Mr. Washington’s medical record, it seems doubtful that it would have changed his decision. That possibility was precluded by Dr. Iinuma’s lack of understanding of the patient’s illness and lack of interest in learning about the condition before rejecting a therapy that, by his own admission, he knew nothing about. Dr. Iinuma cannot be the first medical director to sign off on a decision that he was not qualified to make; he was just the first to be caught.

Aetna is now under investigation by California Insurance Commissioner Dave Jones, who told CNN, “If the health insurer is making decisions to deny coverage without a physician actually ever reviewing medical records, that’s of significant concern to me as insurance commissioner in California—and potentially a violation of law.”⁸

The Way Forward

Mr. Washington had the right idea. If a patient’s insurer makes a decision that seems to lack foundation, it may be time to call for an external referee. Instead of taking the insurance company to court, you may want to start by involving your state’s insurance commission. Truly egregious cases can be referred to your state’s attorney general. Either might help encourage the insurer to do the right thing. Longer term, however, we need more than better enforcement of existing laws; we need better laws.