GRIEVANCES & COMPLAINTS
You should file a grievance within your insurance company if:
- You have an appeal denial due to specific benefits exclusions or restrictions.
- You want to file a formal complaint regarding any aspect of the services provided by your health care plan.
As with the appeals processes, the process for filing a grievance will vary from health plan to health plan. Be sure to call your health plan’s customer service department to obtain the specific details on how to file a grievance.
Get tips for communicating with your insurance company.
File a complaint with your state’s Department of Insurance if:
The Department of Insurance is a state-based regulatory agency that oversees and enforces state insurance laws. It serves insurance consumers by regulating the industry’s practices and encouraging a healthy marketplace. File a complaint with your state’s Department of Insurance if you believe your health insurance provider is violating the law or its contract with you, or you filed a complaint or appeal with your health insurance company that it has not resolved in a timely manner. Examples include but are not limited to unfair claims denials, delays in claim handling, a refusal of insurance or excessive fees or charges.
How to File a Department of Insurance Complaint
Gather the appropriate information.
Before you call or write the Department of Insurance, you should be prepared with:
- Written permission for the Department of Insurance representative to speak to your insurance company on your behalf (if you call in).
- A copy of your insurance card.
- Pages of the summary plan description or benefit booklet regarding coverage of denied services.
- Your medical information from your physician as well as any supporting medical information such as tests, lab work, x-rays, hospitalization information and any information regarding other medical conditions.
- Appeal information.
- Denial letter(s).
- Notes on any calls you have had with your insurance company.
- Anything else you feel is important to your complaint.
Note: Every Department of Insurance requires different complaint information. Refer to your state’s Department of Insurance website for specific directions. Call and ask what information you will need to provide if you do not have access to the website.
Contact your Department of Insurance.
- Call your Department of Insurance if the appointment date for the service(s) or treatment that has been denied will happen soon. If you expect to receive your treatment within the next month, you should call. Most of the time, the department will try to help you over the phone if it can. When calling you will want to state your situation, what has happened (i.e. what services/treatments are being denied) and what you think needs to be done. The Department of Insurance is there to help you, but don’t be afraid to assert your rights as an insurance consumer.
- Write to the Department of Insurance or submit an online complaint if your situation is not immediate. For example, if you are on a medication that works but your doctor wants to add another treatment and your insurance company is denying the request.
- Include all the documents listed in the previous step.
- Give each item you are submitting with your complaint an item number (and letter if a document has more than one page).
- Include the item number, a description of the item, along with the number of pages, in the body of your complaint letter.
- Make a copy of all the information you include with your letter before sending it.
- Include a daytime telephone number and email in your complaint letter so the Department of Insurance can contact you if it needs clarification. Remember, if you have specific questions you should include them in the complaint letter! The Department of Insurance will investigate and find answers to your questions.
Follow up with the complaint.
After you file a complaint, the Department of Insurance should send you an acknowledgment letter stating that it has received the complaint, a summary of the complaint and a time frame for when it expects to have resolved the issue. If this is too long for you, call and let the department know why. Each Department of Insurance will have a different response time, but on average if you do not hear back within two to four weeks, you can call to make sure it received your complaint.
What Happens After I File a Complaint?
Regardless of the complaint, the Department of Insurance will investigate it. If it cannot provide a solution, it will at least provide you with a detailed explanation of why your coverage was denied.
For example, it may state that a treatment/service is not mandated under state or federal law. For most people, their treatment/service is denied because they did not show proof of medical necessity. If this is the case, the Department of Insurance will provide a detailed explanation as to why.
If the Department of Insurance provides you with documentation from the insurance company stating that the requested treatment/service is not a covered benefit, go back and check that this documentation matches the information you have in your benefit package.