How to File a Health Insurance Claim

Read your benefit booklet carefully before you have a claim. Understand what is and is not covered. Follow all procedures and deadlines for seeking treatment and filing complaints and appeals. The majority of insurance companies maintain a toll-free telephone information and complaint line, and some companies and health maintenance organizations (HMOs) provide special mediation or arbitration procedures for handling complaints.

Here are a few suggestions for handling claim or reimbursement problems:

  • For group coverage, contact your group health benefit plan benefits administrator, if one is available. If there is no benefits administrator or if you have an individual health care policy, you should contact the insurance company or HMO.
  • Submit a written complaint to your health benefit plan, insurance company or HMO specifying your concerns.
  • Ask for explanations in writing and keep good records, including the names of people that you talk to while trying to resolve the matter.
  • If you do not resolve the matter, file a formal complaint with the Office of the Commissioner of Insurance (OCI). A complaint form is available on OCI's Web site.