Does Your Health Insurer Have a Grievance System for Customer Complaints, and Does It Work?

If your health insurance claim is denied, delayed, or underpaid, you could end up paying out of pocket for costs that should be covered, forcing you to get a lawyer and fight the system to get reimbursed after the fact. In the worst case, you could wind up forgoing medical care altogether because you can’t afford the treatment. Wrongful health insurance denials are insidious; not only do you not get the coverage and benefits you’ve paid for, but a claim denial can be damaging to your health. People have died while waiting for their insurance companies to come through for them.

If your insurance claim is denied, you have the right to appeal the insurance company’s decision. You should already know this because your insurer is obligated by law to tell you. But failing to properly inform you of your rights is just one of the many ways insurers can fall down on the job. If the insurance company won’t tell you, we will. Let’s take a look at some of the requirements on insurance companies and your rights concerning a health insurance denial under state and federal laws.

Breach of Contraction, Legal Violation, Insurance Bad Faith

Being able to complain about or appeal a claim denial is fundamental to being able to exercise your rights under a health insurance plan. This ability is so basic that not only is it required by federal and state law, but it is also part of the covenant of good faith and fair dealing implied in all insurance contracts. If a health insurance company fails to follow the law, not only are they in violation of statutes, but they are likely guilty of bad faith insurance practices as well, which opens them up to liability for monetary damages on top of providing you with the coverage and benefits they owe.

Federal Law Provides for Complaints and Appeals

According to the U.S. Department of Health and Human Services (HHS), you have options for filing complaints and appeals covering many aspects of your health care. Different processes and procedures are available for complaints and appeals regarding healthcare discrimination, civil rights violations, privacy violations, complaints about poor medical care received in a hospital, and more. You can also file a complaint or appeal regarding an insurer’s decision regarding your health care, with separate processes for appealing a Medicare decision or the decision of a private health insurer.

If your insurance is improperly canceled, or if the insurer refuses to pay a claim or ends your coverage, you have the right to appeal and have that decision reviewed by a third party. As a first step, you can ask the insurance company to reconsider its decision. The insurer must explain their decision and inform you of your right to dispute the decision they made. You have the right to an internal appeal of the decision, including expedited review in an emergency or urgent situation. You also have the right to appeal to an independent third party, known as external review. Under external review, you can appeal any denial based on the following:

• Where you and the insurance company disagree over medical judgment
• Denial based on a claim that the requested treatment is experimental or investigational
• Cancellation of coverage based on the insurer’s claim that your application contained false or incomplete information

Complaints and Appeals at the State Level

States also set out requirements regarding your right to complain about health care coverage. These requirements might be found in state statutes, agency regulations, or both. In California, for example, the state’s Health and Safety Code allows you to complain about the quality of care or service provided (or not provided) by the insurance company.

Insurance companies operating in California are required by law to have a grievance process in place that resolves complaints filed by customers enrolled in the plan within 30 days. Insurers have five days to acknowledge they have received the grievance and provide the grievant with the name of a contact person they can reach out to for updates on how the grievance is moving through the system and how the company plans to respond to the grievance. The insurer’s decision must be provided to the grievant in writing, and it must include the rationale for the decision. If the grievance involves a health emergency, the insurance company has until the end of the next business day to address the grievance.

Insurance companies must clearly explain to policyholders how they can file a grievance. The insurer must also inform policyholders about their ability to request assistance in filing a grievance, including providing interpretation services in several different languages to meet the policyholder’s needs.

Sadly, just because the law requires insurers to have a grievance system doesn’t mean the insurance company is listening. The California Department of Managed Health Care (DMHC) is tasked with protecting consumers’ healthcare rights and ensuring a stable healthcare delivery system. DMHC contains an Office of Enforcement to enforce the state’s managed healthcare laws and force health plans to change their behavior when they are not complying with the law. DMHC frequently cites companies like Anthem and others for failing to properly implement their grievance system in accordance with the law.

You Have Rights to Complain or Appeal Health Insurance Claim Denials

The upshot is that you definitely have the right to complain about the service your health plan is providing and appeal coverage decisions both internally and externally. If it’s an emergency, the insurer is required by law to respond to you quickly. You might need to get a lawyer to fight for you and get what you are owed. In many such cases, the insurer is found to be acting in bad faith, which could entitle you to not just the benefits you are owed but also compensation for any harm done to you, including physical and emotional harm, additional medical costs, and more. Don’t hesitate to look for help from an insurance law attorney who will offer a free consultation to learn about your situation and take your case on contingency, only charging a fee if they are successful in getting you the coverage you need and deserve and possibly additional compensation as well.