Recently I received a call from a consumer who was having a problem with her health insurance. She had had surgery several months ago, and, before her surgery, she had received a verbal approval from her insurance company. Now the insurer is denying the claims for the surgery. She wanted to know what she could do.

There are several ways she can appeal the health insurer's denial. She can contact the insurer directly to complain or to file a grievance. Health insurers in Wisconsin must have procedures to review consumer complaints and grievances. If her coverage is provided through her employer, she may contact the employee benefits department where she works. Many employers have benefit specialists to help employees resolve insurance problems. I also asked her to file a written complaint with OCI so that we could contact the insurer on her behalf and investigate her problem.

Complaint

If you disagree with the insurer's decision, call the plan. Explain why you disagree and ask the insurer to review its decision. It is a good idea to keep a record of any phone call or other contact that you make to the insurer. Note the date and time of the call, the name and title of the individual you talked to, and a summary of what you were told. If you are told that the insurer will investigate and get back to you, ask when you can expect a response.

If your dispute involves proposed medical treatment, you may want to discuss the insurer's decision with your health care provider. You may be reassured to find that there is an alternative treatment plan that will provide a good medical outcome. If your doctor does not agree with the insurer's decision, he or she may be able to provide additional information to support your request.

Grievance

You also may file a grievance--any written statement of dissatisfaction with your health plan--at any time. You may file a grievance because your claim was denied or was not fully paid, because the plan has denied your request for a referral, because you have problems getting an appointment, or because you are dissatisfied with any other aspect of the plan. To file a grievance, send a letter to the insurance company asking it to review its decision. Be sure to include your full name and identification number. In your letter, explain your problem, what you have done to resolve it, and what you want the plan to do. Be as specific as possible. Keep the letter brief and factual. Provide copies of any documentation, such as correspondence or medical records, that support your request. (But don't send any originals; keep those for your own records.) You may also wish to ask your doctor to provide you with a letter explaining the medical reasons for your request.

The health plan must acknowledge that it received your grievance within five business days. Some plans will immediately review your grievance to try to resolve the problem. If your plan cannot resolve the problem to your satisfaction, the grievance will be reviewed by the plan's grievance panel. You have the right to attend the grievance panel's meeting to provide additional information and to question the panel members. If you cannot attend, you can participate by telephone. This is often a good opportunity to clear up any misunderstandings and to explain why you believe the treatment should be covered. It also allows the grievance panel to explain the plan's decision.

The plan generally has 30 days from the date it receives your grievance to send you a letter explaining its resolution. If it cannot resolve your complaint in that time period, it is allowed to take an additional 30 days. This may happen, for example, if the health insurer needs to request medical records from a non-plan doctor. The insurer must notify you in writing that the review will take longer than 30 days, tell you why, and let you know when it expects to complete its review.

If your grievance concerns treatment that you need immediately, ask that the grievance be resolved as an expedited grievance. The plan must review your grievance more quickly whenever the time frame for the standard process could affect your life or health or ability to regain full function. The plan must resolve an expedited grievance within 72 hours.

OCI Complaint

Whenever you have a question or a complaint about your insurance coverage, you can contact the OCI. You can contact the OCI by calling or by e-mailing at the numbers at the end of the article. You can also file a written complaint. OCI investigates every complaint it receives in order to assist you in resolving your complaint, and to determine if the insurance company is complying with all Wisconsin insurance laws.

This article is one of a series written by Barbara Belling, Managed Care Specialist for the Office of the Commissioner of Insurance. She can be reached by electronic mail at ocihmo@wisconsin.gov. The OCI's brochures "Fact Sheet on Managed Care Consumer Protections in Wisconsin" and "Managed Care Health Plans in Wisconsin" are available toll-free at 800-236-8517 or on the Internet at http://oci.wi.gov.

By Barbara Belling
Office of the Commissioner of Insurance