Hassle-Free Health Coverage: Disputing Decisions
Unlike HMOs (which usually have to respond within six months), traditional indemnity plans are not required to respond to your complaints within a set time frame or have provisions for a formal hearing or appeals process. But if you are not satisfied with your insurer's willingness to pay a claim, you can ask for a reconsideration of the decision.
If you have problems getting reimbursed, an indemnity plan allows you to choose your method of recourse, i.e., the court system or mediation. In addition, you have the option to appeal any decision by your insurance company to pay or deny a claim.
You can also file a complaint with your state's Department of Commerce (or equivalent agency)-and you don't have to tell your insurance company first. You will have to fill out a complaint form and supply any information needed to support your position to the Department.
Department investigators will usually then contact your insurance company; and, if the problem cannot be resolved within about 10 days, they will investigate whether the insurance company followed the terms of your policy.
