stamp of approvalDepartment of Insurance

When should I contact my state’s Department of Insurance?

Recruit the help of your state’s Department of Insurance if your insurance company has denied you medical service(s) or treatment that is covered or that you feel should be covered in your plan.

What is the Department of Insurance?

The Department of Insurance is a state-based regulatory agency that oversees and enforces state insurance laws. It serves insurance consumers by regulating the industry’s practices and encouraging a healthy marketplace.

How do I file a complaint with my state’s Department of Insurance?

  • Gather the appropriate information
    Before you call or write the Department of insurance, you should be prepared with:

    • Written permission to speak to your insurance company on your behalf (if you call in)
    • A copy of your insurance card
    • Pages of the summary plan description or benefit booklet regarding coverage of denied services
    • Your medical information from your physician as well as any supporting medical information such as tests, lab work, x-rays, hospitalization information and any information regarding other medical conditions
    • Appeal information
    • Denial letter(s)
    • Notes on any calls you have had with your insurance company
    • Anything else you feel is important to your complaint

    Note: Every Department of Insurance requires different complaint information. Refer to your state’s Department of Insurance website for specific directions. Call them and ask what information you will need to provide if you do not have access to their website.

  • Contact your Department of Insurance

    • Call your Department of Insurance if the appointment date for the service(s) or treatment that has been denied will happen soon. If you expect to receive your treatment within the next month you should call. Most of the time, they will try to help you over the phone if they can.

      When calling you will want to state your situation, what has happened (i.e. what services/treatments are being denied) and what you think needs to be done.

      The Department of Insurance is there to help you, but don’t be afraid to assert your rights as an insurance consumer.

      Tips for Communicating with Your Insurance Company

    • Write to the Department of Insurance or submit an online complaint if your situation is not immediate. For example, if you are on a medication that works but your doctor wants to add another treatment and your insurance company is denying the request.

      • Include all the documents listed in Step 1.
      • Give each item you are submitting with your complaint an item number (and letter if a document has more than one page).
      • Include the item number, a description of the item, along with the number of pages, in the body of your complaint letter (as shown in template letter). [hyperlink]
      • Make a copy of all the information you include with your letter before sending it.
      • Include a daytime telephone number and email in your complaint letter so they can contact you if they need clarification.

    Remember, if you have specifics questions you should include them in the complaint letter! The Department of Insurance will investigate and find answers to your questions.

  • Follow up with the complaint

    After you file a complaint, the Department of Insurance should send you an acknowledgment letter stating that they have received the complaint, a summary of the complaint and a time frame for when they expect to have resolved issue. If this is too long for you, call them and let them know why.

    Each Department of Insurance will have a different response time, but on average if you do not hear back from them within 2-4 weeks (or sooner if it’s an emergency) you can call to make sure they received your complaint.

What happens after I file a complaint?

Regardless of the complaint, the Department of Insurance will investigate it. If they cannot provide a solution, they will at least provide you with a detailed explanation of why your coverage was denied.

For example, they may state that a treatment/service is not mandated under state or federal law. For most people, their treatment/service is denied because they did not show proof of medical necessity. If this is the case, the Department of Insurance will provide a detailed explanation as to why. 

If the Department of Insurance provides you with documentation from the insurance company stating that the requested treatment/service is not a covered benefit, go back and check that this documentation matches the information you have in your benefit package.

 
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The information provided on the PHA website is provided for general information only. It is not intended as legal, medical or other professional advice, and should not be relied upon as a substitute for consultations with qualified professionals who are familiar with your individual needs.

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The National Organization for Rare Disorders (NORD) awarded PHA the Abbey S. Meyers Leadership Award in 2012 for outstanding service to PHA members in advocacy, education and other key areas.