ABA Family Legal Guide

Health-Care Law

Health-Care Options

Health Insurance and Managed Care Organizations

What can I do if I have a dispute of this kind with my health insurance company or plan?

If a health insurance company or plan denies your claim or refuses to provide a benefit or service, you have several options.

Seek Internal Review

Health insurance companies and plans are required to establish rules and procedures for handling complaints and grievances internally. Utilizing these procedures is an important first step in seeking resolution of a dispute. You can start an internal review with a phone call to a complaints hot line. You may need to follow it up with a complaints form or a written complaint.

. Check your policy to see how long a review is likely to take—it can be anything from one business day to thirty days. If your dispute concerns the medical necessity of services to be provided and waiting for a standard review would seriously jeopardize your health, you may be eligible for an expedited review, and the plan will evaluate your dispute sooner.

Seek External Review

External review allows your case to be reviewed by a third party independent of the health-care plan. Most states have external review procedures, which can be pursued once internal review has been exhausted. Your health-care plan or insurance company may automatically refer your dispute to external review if your internal review is unsuccessful; or you may need to request external review in writing within a certain time period after internal review.

Most states will not review all disputes, only those involving "medical necessity." That means that there must be a dispute between you and your health plan over whether a particular procedure, treatment, or pharmaceutical is essential for your health and recovery.

The external review procedures are different in each state, but are usually free or available for a small fee.

Complain to the Accrediting Organization

Most HMOs are accredited with nongovernmental groups such as the National Committee for Quality Assurance (www.ncqa.org), the American Accreditation HealthCare Commission/URAC (www.urac.org), and the Joint Commission on Accreditation of Health Care Organizations (www.jcaho.org). HMOs rely on their accreditation by these organizations in their marketing to employers and unions. Making a well-documented complaint to the relevant organization and sending a copy to your HMO might have results.

Make a Complaint About Your Doctor—and Seek a Second Opinion

If you think your doctor is withholding treatment, then talk to your doctor about it. You might want to seek a second opinion about whether treatment is necessary. And if you believe your doctor is withholding treatment for his or her own pecuniary gain, you can file a complaint with your state's medical board.

Appeal to the State Insurance Department

This is a good option if you are covered by an HMO. Since all plans have to be licensed by a state's insurance department, these departments truly do have the last word. They are especially useful if you feel there has been discrimination, unfair denial, or a vagary of the rules, disclosures, or booklets. HMOs are likely to respond out of concern that their license might be revoked or suspended.