5 tips on how to pursue a complaint against your health insurer

As many of California’s newly-insured are fast learning, there are few things about health coverage that are simple.  Everything from the industry lingo (stuff like “copays,” “coinsurance” and “actuarial value” ) to the alphabet soup of health policies, (think HMOs, PPOs and EPOs ) can exhaust even the most savvy consumer.

And making things just a bit more confusing:  California has a bifurcated regulation system, which means there’s no one agency that takes all of the complaints and questions.  Instead, oversight of your health plan is with either the Department of Managed Health Care (DMHC) or the California Department of Insurance (CDI).

“Health insurance is complex and there are all sorts of opportunities for  (individual consumers) and employers to get confused,” said California Insurance Commissioner Dave Jones.  

The rising number of consumer calls to both agencies this year bears that out.  For instance, the DMHC, which regulates a majority of California’s health plans, has already received 67,000 "consumer contacts," as it calls any complaint, letter or call to the agency. That figure already exceeds the 66,000 contacts the agency received in 2013, said DMHC spokesman Rodger Butler.

Complaints, which include denial of a particular treatment or the inability to find a doctor in your network, are also on the rise.  So far this year consumers have filed nearly 3,600 complaints with DMHC, which is fast approaching the 4,411 logged with the agency in all of  2013, Butler said. 

The 2014 increases stem in part from the sheer the number of formerly uninsured Californians who now have coverage. Since the Affordable Care Act begin requiring nearly every American to have health insurance, nearly 3.5 million Californians have enrolled in a health plan, recent studies show. 

So what should you do if you have a problem with your health insurer? Here are five tips:  

 1) Know the specifics of your policy.  First, know which insurance company issued the plan: Anthem Blue Cross? Blue Shield? Health Net? Kaiser? Another company? Second, know whether you have a group policy or an individual/family policy. Group policies are those sold by an employer or an association. Individual/family policies are those you buy on your own: either through a broker; directly from the carrier; or through the Covered California marketplace. Third,  know which type of plan it is: HMO, PPO or EPO?

2) Ask your insurer to do the right thing. Step one: contact your health plan by phone, in writing or through its webpage and explain the problem.  Then, make sure to keep detailed notes of any conversations you have with your insurer's representatives.  If you phone, write down the date of your call, the name of the person you talk to, and what the person says. The DMHC also provides these additional tips when communicating with your health plan:

•  If you are told that you cannot get the care you need, ask for the reason in writing.
• Talk to your doctor about your problem.
• Have someone with you for extra support.
• Find answers to common questions people have about the complaints process here.

3) If you don't get satisfaction, it's time to file a complaint. If you're unsatisfied with the response from your insurance company, or your insurer doesn’t make a decision about your issue within 30 days, or if your health problem is urgent (such as a denial of coverage that poses a serious threat to your health), it's time to get formal. You'll want to contact the agency charged with regulating your plan, either the DMHC or the CDI, and file a complaint. 

The easiest way to find out which agency oversees your plan is to call the consumer hotline number for either agency and ask a representative.

The consumer hotline for DMHC is (888) 466 2219.   For CDI it’s (800) 927-4357.

4)  Ask for an Independent Medical Review. An Independent Medical Review (IMR)  is a process offered by both the DMHC and CDI.  It involves a panel of doctors outside your plan who review your case and determine the proper course of care. Then, the health plan is required by law to follow the panel’s recommendation. About 60 percent of enrollees who go through this process "get the care they were interested in getting," Butler said.  But note that to qualify for an IMR, you must request it within six months of the decision from your insurance company.

5) If the IMR goes against you, all is not necessarily lost. If a review is not decided in your favor, you cannot appeal to a higher power. You may have the option of pursuing a legal remedy, but you'd need to speak with an attorney about that.