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 independent medical review; and
  • 3. File a complaint.

If your insurer denies your claim, you have the right to an internal appeal, known in Indiana as an “internal grievance.”[1] This means you can ask your insurer to conduct a full and fair review of its decision. To file an internal grievance, 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 all of 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.[2]
  • 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 grievance process should take a maximum of 45 days.[3] You can skip the internal grievance process and request an expedited external grievance review in urgent situations.[4] Your situation is urgent if waiting 45 days would seriously jeopardize your life or your ability to regain function. 

If your insurer still denies you coverage after you filed an internal grievance, you can request an external grievance review of your insurer’s decision. If your situation is urgent, you can request an expedited external grievance review.[5] During an external grievance review, an independent third party reviews your insurer’s decision.[6]

You should file your request for a standard or an expedited external grievance review with your health insurer within 120 days of the most recent determination letter.[7] Your insurer must provide you with information on how to submit your request.[8] Be sure to carefully read your insurance policy and any documentation you received with your determination letter to ensure that you follow your insurer’s instructions closely.[9]

Once your insurer receives your request, it will submit your materials to an independent review organization. An independent reviewer will conduct an investigation and render a decision.[10]

The external grievance review process should take no more than 15 days after the external grievance is filed.[11] If you request an expedited external grievance review, the process should take no longer than 72 hours after your request is received.[12]

If you are an Indiana resident and you have completed the internal appeal and external review processes but still lack access to a treatment, you can file a complaint with the Indiana Department of Insurance (“Department”).

Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“applicant”);
  • The name of the insured person;
  • The name and address of insurance company;
  • The state where the insurance plan was purchased;
  • Policy number and claim number;
  • If a group policy, the name and address of the employer; and
  • The details of the complaint.[13]

You must also submit the following supporting documents:[14]

  • A copy of your insurance card;
  • Copies of coverage denials or determination letters 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 practitioner;
  • A copy of your insurance policy; and
  • All responses from your insurer.[15]

The complaint may be submitted online here, faxed to (317) 234-2103, or mailed to the following address:

Indiana Department of Insurance
Consumer Services Division
311 W. Washington Street, Suite 300
Indianapolis, IN 46204-2787[16]

The Department will process your complaint within 72 hours.[17] You will receive a confirmation letter that includes your problem report number and the name of the Consumer Consultant handling your case. The Consultant will send a copy of the complaint to your health insurer. Your insurer must respond to the complaint within 20 days. The Department will then provide you with a decision.[18] If the Department determines that insurer violated a law, regulation, or policy, the Department may take corrective action against the insurer, including fines or a lawsuit.[19]

You can contact the Indiana Department of Insurance at (800) 622-4461 or (317) 232-2426. The Department if open from 8:00 a.m. to 4:15 p.m. Monday through Friday.