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Appeals and Complaints


When you take on ownership of an individual health insurance plan, you may run across certain times when you aren’t in love with your health plan or you’re wanting to fire an agent. Instead of getting irate, you can go about the proper method of filing a complaint. If the issue you face is in regards to a claim that your insurance company refused to cover, you are welcome to file an appeal. It is your right as a policy owner to know what you are entitled to, and many time confusion arises and claims are not rightfully denied.

The first place to go? Try sorting out your problem directly with your insurance carrier. This is the best way to resolve any issue. Every health insurance company has a department devoted specifically to handling consumer complaints, and they should be able to figure out what went wrong.

 

Contact Your Health Insurance Company

Your health insurance card will likely include the correct phone number for address your complaints, whether listed as Customer Support or otherwise. Additionally, you can contact some insurers regarding appeals or complaints through their website. Company sites usually contain an online form you can fill out to file an appeal, such as the links listed below.

The most effective way to file a complaint or grievance with Kaiser Permanente is to send an email describing your situation. This ensures that you have a copy of your having sent the complaint, while filling out the form through the website creates no paper trail on your end. Send an email to mscc@kp.org if you have an issue.

 

Aetna Appeals & Complaints

Coventry One Appeals & Complaints

Kaiser Permanente Complaints

Kaiser Permanente Member Services

D.C. metro area 301-468-6000

Other areas 800-777-7902

UnitedHealthOne Support

800-657-8205

 

Contact the Maryland Insurance Administration

 

Complaints

If you feel your insurance company has been participating in illegal business practices, contact the MIA for assistance if you have been unable to resolve your issue with the carrier. While they will not be your legal representative or take part in a lawsuit, they can help you bridge the communication gap between you and the insurer. When you file a complaint with the MIA, they will forward a copy to the insurance company (if appropriate) and then they will acquire information or explanations from the insurance company or their representatives.

Once they hear from the company or their representatives, the MIA will review the company’s response in detail for compliance with policy contracts, statutes, and regulations. Afterwards, the Insurance Administration may explain your health plan’s provisions, if necessary, and give you suggestions on how to proceed which could help resolve your issue. If it is determined that your health insurer has violated a policy, regulation, or statute enforced by the MIA, the organization may take corrective action against the company.

To file a complaint, view the Maryland Insurance Administration’s instructions on how to complete a complaint form. Or use their online form.

 

Appeals

If your insurer has denied a claim and you have read over your policy and found that the service should have been covered, and you have not been able to resolve the claim denial with your insurer, you may file an complaint about your claim through the Maryland Insurance Administration. They will assign an investigator to your case in order to reach an outcome, and the form you submit will include authorization for release of medical information in order to make the process go smoothly.

Complaint forms for appeals can be filed here.

 

 

Sources:

 

1. Maryland Insurance Administration. “File a Complaint”. http://www.mdinsurance.state.md.us/sa/consumer/file-a-complaint.html.

2. Maryland Insurance Administration. “Appeals and Grievances”. http://www.mdinsurance.state.md.us/sa/consumer/appeals-and-grievances.html

 

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