Insurance Commissioner Urges Consumers to Challenge Treatment Denials

Insurance Commissioner, Dave Jones, issued a statement urging policyholders to challenge their insurer if the company denies their claims for treatment. He reminds policyholders they have a right to appeal to the company and ask CDI to review the denial. There is also a fair chance a review of the decision could go in their favor.

According to the California Insurance Code, when insurers deny requested treatment as not a covered benefit they are required to give policyholders the specific provisions in their policy that exclude coverage. In addition, if companies deny coverage for a treatment as not medically necessary, they are required to outline the facts and law on which they based their denial.

Jones said, “If your health insurer won’t initially cover your treatment, that’s not the end of it. As a consumer, you have options. You may file a request for assistance with my department whenever you have problems with an insurer involving a claim. Denial by an insurance company is not the final word. If your claim was denied because the insurer determined the treatment is not medically necessary or was experimental, you may request an independent medical review (IMR) from the Department at no cost to you. However, you must first file an appeal of the denial with your insurance company, using the company’s internal appeals/grievance process.”  For more information, visithttp://www.insurance.ca.gov/0100-consumers/0020-health-related/0020-imr/upload/

HCB002IMR.pdf

Last Updated 9/8/2017

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