If you are a West Virginia resident and your insurer denies your coverage after the external review process, you can file a complaint with the West Virginia Offices of the Insurance Commissioner Consumer Services Division (“Division”).

Complaint information. You can find a copy of the complaint form here. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name of the patient and name of the insured, if different than the Complainant;
  • The names of other parties involved in the claim;
  • The name of insurance company;
  • The type of coverage, policy number, claim number, and date of loss;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[14]

Supporting documents. You should submit the following supporting documents with your complaint:

  • A copy of your insurance card;
  • Copies of coverage denials or adverse benefit determinations from your insurer;
  • Copies of any determinations made by internal and external reviewers;
  • Any materials submitted with prior appeals and complaints;
  • Supporting documentation from your health care provider;
  • A copy of your insurance policy; and
  • All responses from your insurer.[15]

How to submit. The complaint and supporting documents can be faxed to (304) 558-4965 or mailed to the following address:

Consumer Services Division
West Virginia Offices of the Insurance Commissioner
P.O. Box 50540
Charleston, WV 25305-0540[16]