Health Insurance Grievance and Appeals - When You Don't Agree
Hypothetically, what would happen if your medical insurance company denied a claim you felt sure should have been covered? There is a process for health insurance grievance and appeals to assist with just such instances. The exact process, what situations qualify, and your rights as a consumer vary widely from state to state. Some states mandate that insurance companies allow consumers a formalized method for having a denied claim reviewed. However, someone within the insurance company often conducts the reviews. Very few states require grievances or appeals to be handled by a neutral third party.
Each state has different laws governing the topic of health insurance grievance and appeals, although typically they require similar processes. Generally speaking, the consumer must first officially request an appeal or file a grievance with the insurance company. This could be as simple as filing out a form or sending a letter. What happens next is what varies from state to state. Some states require the insurance company to respond or provide a decision within a certain amount of time. Once the review process is complete and a decision is reached, certain states allow consumers to further appeal a decision they feel is not in their favor.
Other states have a different approach to health insurance grievance and appeals. In these states, an official appeal or filing a grievance bypasses the insurance company and goes straight to a third party reviewer. In other states, once an initial review is conducted by the insurance company, the only option left to a consumer is to file a complaint with the state's insurance commissioner or other regulatory body. In these situations, the process can be a long one, resulting in consumers paying out of pocket for treatments and procedures while going through the appeal process or filing a complaint with government officials.
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