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:

  • Appeal the decision;
  • Request an external review; and
  • 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 all 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 30 days.[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. Under Oregon law, you are entitled to request an external review in the following circumstances:

  • If your insurer denies your coverage after an internal appeal because it determined that the requested treatment or service were medically unnecessary, experimental/investigational;
  • You are trying to avoid a disruption in your care; or
  • You are disputing the appropriate setting for treatment or the appropriate level of care; or
  • Your health insurer rescinded or ended your coverage.[4]

You can request an expedited external review if your medical situation is urgent and waiting would jeopardize your life or health.[5] You should request the expedited external review at the same time that you request the internal appeal.

You should submit your request for external review to your health insurer, which will forward your request to the Division of Financial Regulation (“Division”).[6] The Division will then randomly assign your case to an external review organization.[7]

You must file your request within 180 days from the date that your insurer sent you the final decision.[8] You should include any additional information and documentation that you did not include with your previous request for an internal appeal with your request for an external review, including medical records and recommendations of your treating health care provider or providers.[9] Be sure to note on your application whether you are requesting a standard or expedited external review.

The external review process should take no more than 30 days after you apply to the insurance company for external review.[10] If you requested an expedited external review, the process should take no more than three days after your request is received.[11]

If you are an Oregon resident and your claim is denied after the external review process, you can file a complaint with the Division.

Complaint information. Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
  • The names of other parties involved in the claim;
  • The name of insurance company;
  • The policy number, claim number, and date of loss;
  • The reason for the complaint;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[12]

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

  • A copy of your insurance card;
  • Copies of your 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 provider;
  • A copy of your insurance policy; and
  • All responses from your insurer.[13]

How to submit. The complaint may be submitted online here, faxed to (503) 378-4351, or mailed to the following address:

Department of Consumer & Business Services
Insurance Division
P.O. Box 14480
Salem, OR 97309-0405[14]

Once you have filed your complaint, you will be notified that your complaint has been received and assigned to an advocate.[15] The advocate will send a copy of your complaint to your health insurer for a response. Your health insurer has three weeks to respond.16] The advocate will analyze the response and any supporting documents.[17] Following an investigation, the advocate will notify you of his or her findings. The Division can force the insurance company to comply with the policy, fine the company, or revoke the company’s license.[18] A full investigation may take up to 60 days to complete.[19]

You can contact the Oregon Division of Financial Regulation at (888) 877-4894. The Division is open from 8:00 a.m. to 5:00 p.m., Monday through Friday.