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.[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 telling you that it would not cover your claim. Review this document so you can understand why your claim was denied 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 after your health insurer receives the appeal for services you have not yet received and a maximum of 45 days if you have received the service or treatment but are waiting for reimbursement.[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 Texas law, you are entitled to request an external review if your insurer denies your coverage after an internal appeal because it determines that the treatment is experimental, investigational, medically unnecessary, or inappropriate. You cannot ask for an external review if your policy does not cover the denied services.[4]

You can also request an expedited external review if you or your health care provider believes that your condition is life threatening or if your plan denies coverage for a prescription drug or intravenous infusion for which you are currently receiving benefits.[5] You should call your insurer and find out if you can skip the internal review process if you qualify for an expedited external review.

To request an external review, you should complete the following steps:

Complete request form. Your insurer should have provided you with the external review request form when it sent you the final adverse determination letter.[6] You should complete that form and submit it to your health insurer per the instructions included with the final adverse determination letter. You should also send any new information and documentation that you had not previously included with your request for an internal appeal.

Deadline. While there is no deadline to request an external review, you should file your request as soon as possible after you receive your determination letter.[7]

Next steps. Your health insurer will send the request to the Texas Department of Insurance (“Department”), which will assign your claim to an independent review organization.[8]

The external review process should take no more than 20 days from the date the external review organization receives your request.[9] If you requested an expedited external review, the process should take no longer than three business days after your request is received.[10]

If you are a Texas resident and you believe your insurer has done something illegal or unethical, you can file a complaint with the Department.

Complaint information. You should complete the complaint form located here. Your complaint should include the following information:

  • The name, address, and telephone number of the person filing the complaint (“Complainant”);
  • The name and address of the insured individual, if different than the Complainant;
  • The name of the provider;
  • The name of insurance company;
  • Policy number, claim number, and date of loss;
  • Type of insurance and reason for complaint;
  • The details of the complaint; and
  • What you consider to be a fair resolution.

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

  • A signed medical record release form (included with the complaint packet);
  • 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 submit the complaint and supporting documents by using one of the following methods:

MC 111-1A
Consumer Protection
Texas Department of Insurance
P.O. Box 149091
Austin, TX 78714-9091

  • Deliver in person to the following address:

Texas Department of Insurance
Consumer Protection (111-1A)
333 Guadalupe Street
Austin, TX 78701[12]

Once the Department receives your complaint, it will contact your health insurer and attempt to resolve the dispute.[13] Your complaint will typically be resolved within 45 days from when the Department receives your complaint.[14] The Department can force your health insurer to comply with the policy and take enforcement action, including issuing a citation or fine, if the insurer violated a law or regulation.[15]

You can contact the Texas Department of Insurance at (800) 252-3439. The Department is open from 8:00 a.m. to 5:00 p.m. Monday through Friday.

  • [1] Appealing a Health Plan Decision: How to Appeal an Insurance Company Decision, healthcare.gov,  https://www.healthcare.gov/appeal-insurance-company-decision/appeals/.
  • [2] Tex. Ins. Code §§ 4201.359 and 4201.305 (2016).
  • [3] Appealing a Health Plan Decision: External Review, Healthcare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/external-review/.
  • [4] Independent Review Organizations, texas department of insurance, http://www.tdi.texas.gov/pubs/consumer/cb057.html.
  • [5] Request a Review by an Independent Review Organization, Texas Department of Insurance, https://www.tdi.texas.gov/forms/finmcqa/lhl009urairoreq.pdf.
  • [6] Independent Review Organizations, Texas Department of Insurancehttp://www.tdi.texas.gov/pubs/consumer/cb057.html.
  • [7] Id.
  • [8] Id.
  • [9] Id.
  • [10] Id.
  • [11] Complaint to Federal Government Agency: Patient, Legal Action Center, https://lac.org/wp-content/uploads/2016/04/10-Patient-Federal-Complaint.docx (last visited Oct. 17, 2016).
  • [12] Helping You with Your Insurance Complaint, Texas Department of Insurance, http://www.tdi.texas.gov/pubs/consumer/cb003.html.
  • [13] Id.
  • [14] Id.
  • [15] Id.