Complaints and grievances are ways to draw attention to issues with your insurance company’s service. Those issues range from long hold times and other customer service matters, to concerns that your health insurance plan is breaking the law.
While some grievance processes are designed to address a person’s concerns, others aim to gather information about insurance companies’ practices and hold them accountable. In those cases, your complaint could help future consumers more than it helps you.
If you’re not happy with a coverage decision from your insurance company, and it has denied your appeal, ask what other steps you can take. The next step might be to file a grievance with the insurance company or other entities.
As with appeals, the process for filing a grievance varies among health plans. Call your plan’s customer service department about how to file a grievance.
Other sources to consider
Elected officials
If you have an urgent need for health care and your insurance company isn’t responding promptly, consider contacting the offices of your state or federal elected officials. Each member of the U.S. Senate and House of Representatives, and many state elected officials, have staff who work with their constituents (you) to navigate a variety of challenges. Check your elected official’s website for their contact information, or visit House.gov or Senate.gov.
State insurance entities
Search the web for your state’s Department of Insurance to find the agency in your state that enforces state insurance laws and monitors consumer safety related to insurance services.
File a complaint with the Department of Insurance in your state if you believe your health insurance provider is violating the law or its contract with you. You also can file grievance with the agency if your insurance company hasn’t resolved your complaint or appeal in a timely manner. Examples include unfair claims denials, claim handling delays, refusal of insurance or excessive fees or charges.
Follow the complaint process outlined by the agency. If your concern is urgent, consider beginning with a phone call. When you call, make sure you have:
- Your health insurance card or plan identification details.
- Claims or appeals documentation previously submitted to your health insurance company about your concern.
- Denial letters or other documentation related to your concern.
Next steps
After you file a complaint, the state insurance department should send you a letter acknowledging that it has received the complaint, a summary of your complaint and a time frame for when it expects to have resolved the issue.
If the time frame seems too long, call and let the department know why. Each agency will have different response times, but if you don’t hear back within two to four weeks, call to make sure it received your complaint.
Regardless of the complaint, the department of insurance will investigate it. If it can’t provide a solution, it at least will give a detailed explanation of why your coverage was denied. For example, it may state that a treatment or service isn’t required under state or federal law. If the agency provides documentation from the insurance company that says the requested treatment or service isn’t a covered benefit, check that the documentation matches the information in your benefit package.