Anna Liss-Roy ’20
In February 2018, California’s insurance commissioner opened an investigation into Aetna, an American managed healthcare company, after a company medical director testified in a deposition that he never looked at patients’ medical records when deciding whether to approve or deny coverage.
Plaintiff Gillen Washington had sued the health insurer in 2016 after being denied coverage for a rare immune disorder with treatments that can cost up to $20,000. The California Department of Managed Health Care and the California Department of Insurance consequently launched an investigation into Aetna’s policies and procedures for deciding whether to approve or deny claims.
The case was settled a year later, in early 2019, with the terms of the agreement unreleased.
The attorney representing Washington was Scott Glovsky, a Los Angeles bad faith and Pasadena personal injury lawyer, whose clients have been featured in People Magazine, CNN, CBS and the Oprah Winfrey Show. “What we do is we represent patients who are denied medical care by their insurance companies, that’s the focus of our practice,” said Glovsky in an interview. “[Aetna] had a system of denying people without viewing their medical records.”
This system stems from the design flaw that individuals hired by insurance companies to make decisions about whether to approve or deny coverage are trained to apply the company policy – and may not themselves be a physician. “Insurance companies are so policy-driven now that what they’re doing is developing very broad policies for certain treatments, having them apply across the board, even though it’s not a one-size fits all case,” said Glovsky.
This case carries layered implications for members of the Claremont community, given the vulnerabilities of certain demographics to predatory calculations made by insurance companies, as well as the fact that Aetna is the Exclusive Provider Organization for the Student Health Insurance Plan offered by the Claremont Colleges.
Glovsky offered advice for students worried about predatory insurance policies that could deny them care. “Make sure that you don’t take no for an answer, that whenever medical treatment is denied you get letters from your physicians explaining why it’s medically necessary,” said Glovsky. “The key is to follow the doctors and to document everything and to not take no for an answer.”
According to Glovsky, insurance companies take advantage of those who they are least able to fight for themselves. This includes populations like the elderly, but it also includes areas of coverage, such as mental healthcare.
“In the area of mental health, it’s another area where it’s easy for the insurance companies to take advantage because it’s subjective. It’s not like you can take an MRI to show you have [certain mental illnesses],” said Glovsky.
This system is universal among healthcare companies in the U.S. and requires due diligence by those in need of care.
If you are denied care by your insurance company:
1. Before the denial even happens, play defense. Keep detailed records including dates, times, and names of those you speak with at your insurance company. Request confirmations of recommendations and changes in writing so you have a record. If you have the time, read your plan so you can use the language to advocate for why your treatment is in line with the requirements of your plan.
2. Don’t take no for an answer: fight the denial. Get letters from your physicians explaining why the treatment is medically necessary.
3. Ask your doctor about alternative treatments or medical options.
4. If possible, pay cash for the service. If this is not possible for you, try raising money among family and friends.
5. Consider proposed reforms to the healthcare system, many of which would alleviate the grip of these predatory practices on those most unable to fight back.
Image Credit: City of Claremont