Health Insurance Complaint
10. What if I Am Not Satisified with My Care?
[Health insurance and medicine are regulated and there are procedures for addressing a health insurance complaint. Is the problem about the quality of care, or a health insurance complaint about what the plan covers? - ed.]
Getting the best care and services means understanding how your health plan works, what your rights are, and how to complain if you need to. You have the right to get copies of test results as well as medical information about yourself. If you are in a managed care plan, you can ask to change your primary care doctor if you are unhappy with the relationship. You may also be able to switch plans during open enrollment.
[If you have a health insurance complaint, switching plans during open enrollment typically refers only to employer group plans. With individual coverage, depending on the nature of the health insurance complaint, the remedy may be to buy something else, which can be applied for anytime. - ed.]
Most plans have an appeals process that both you and your doctor may use if you disagree with the plan's decisions. If your plan refuses to provide or pay for services, you can complain or file a grievance about any decision you feel is unfair—or you can appeal it.
You can contact the member services division of your plan for more information or to complain. Use your plan's complaint process fully before taking other action.
Be sure to keep written records of:
- All correspondence with the plan.
- Claims forms and copies of bills.
- Phone conversations—the date and time, the people you speak with, and the nature of each call.
If the plan does not satisfy you, you may decide to bring the matter to the attention of your employee benefits manager, your State insurance commissioner, your State department of health, or the legal system. If you are a Medicare or Medicaid beneficiary, you have additional ways through those programs to file a grievance about the care received from a plan or provider. For information, contact your State's medical Peer Review Organization or State Medicaid Program.
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[Before making a health insurance complaint to the state insurance regulator, it would be helpful to be able to specify which particular law, regulation, or coverage provision seems to have been violated. A health insurance complaint is often the consequence of a misunderstanding. If the health insurance complaint is strictly an insurance problem, the agent/broker/producer who sold the plan may be able to provide independent help.]