My insurer refuses to cover my prescribed treatment. What can I do?

If your insurer denies your coverage, you can challenge your insurer’s decision by completing the following steps in order:

  • 1. Appeal the decision;
  • 2. Request an external independent review; and
  • 3. File a complaint.

If your insurer denies your claim, you have the right to an internal appeal.[1] This means you can ask your insurer to conduct a full and fair review of its decision. To appeal the denial, you should do the following:

  • Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
  • Collect information. In addition to the determination letter, collect the documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
  • Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
  • Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
  • Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
  • Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

The internal appeals process should take a maximum of 45 days from the date that the insurer received your request for appeal.[2]

During an external review, an independent third party reviews your insurer’s decision.[3] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. Pursuant to Delaware’s Independent Healthcare Appeals Program, you are entitled to request an external review if your insurer denies you coverage or preauthorization request after you requested an internal appeal.[4]

You can skip the internal appeals process and request an expedited external review if you have a condition that poses an imminent, emergent, or serious threat or have an emergency medical condition.[5]

You should submit a request for an external review to your insurer by completing an appeals form that your insurer provides to you within four months from the date on the first appeal denial letter.[6] Be sure to inform your insurer on the appeals form whether you are seeking a standard or an expedited external review.

Your insurer will then forward the request to the Delaware Department of Insurance with an email outlining the plan type and the reason for the denial of coverage.[7] The Department will then refer the request to an independent outside review organization. The insurer must submit complete plan information, complete claim information, and all medical records and other documents used to make its decision to the review organization.[8] The reviewer will select three independent medical providers to review the appeal and provide a final decision.[9]

The external review organization should respond to you within 45 days of receiving the application. If you request an expedited external review, the process should take no more than three business days after your request is received.[10]

If you are a Delaware resident and your insurer denies your coverage after the external review process, you can file a complaint with the Delaware Department of Insurance (“Department”).

Complaint information. Your complaint should include the following information:

  • The name, age, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The name of the insured individual, if different from the Complainant;
  • The names of any other parties involved in the claim (for example, the plan administrator);
  • The name of insurance company and the type of insurance;
  • The policy number, certificate number, claim number, date of loss or service, and reason for the complaint;
  • What you consider to be a fair resolution.

Supporting documents. You should also 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.[11]

How to submit. You can complete and submit a complaint online here. If you submit an online application, you should electronically attach supporting documents to the online complaint. Alternatively, the complaint and supporting documents can be faxed to (302) 739-6278 or mailed to:

Delaware Department of Insurance
Consumer Services Division
841 Silver Lake Blvd.
Dover, DE 19904[12]

The Department of Insurance will assign someone to investigate your complaint.[13] The That representative may question witnesses, request additional documents from other parties, and hold a hearing.[14]

You can contact the Delaware Department of Insurance at (302) 674-7310 or (800) 282-8611.  The Department is open from 8:00 a.m. to 4:30 p.m. Monday through Friday.