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 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 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 if you have not yet received the requested service or treatment and a maximum of 60 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 Vermont law, you are entitled to request an external review for

  • Any denial that involves medical judgment where you or your provider may disagree with the health insurance plan
  • Any denial that involves a determination that a treatment is experimental or investigational
  • Cancellation of coverage based on your insurer’s claim that you gave false or incomplete information when you applied for coverage.[4]

You can also skip the internal appeal process altogether and request an expedited external review if your medical situation is urgent and waiting would jeopardize your life or ability to function.[5]

You should submit your request for an external review to the Vermont Department of Financial Regulation (“Department”).[6] You can find a copy of the external review request form here.

Information. You should include the following information in your request:

  • The name, address, and telephone number of the patient;
  • The name, address, and telephone number of the insurance company;
  • The name of the person at the insurance company involved with your appeal;
  • Subscriber or member number and insurance claim or reference number;
  • Brief description of decision in dispute; and
  • The name, type of provider, address, and telephone number of your health care provider.

Filing fee. You must submit a $25 filing fee by check or money order with your request. The fee can be waived for financial hardship.[7] If you believe you have a financial hardship, you should complete the “Request to Reduce or Waive Filing Fee” section of the external review request form (bottom of page 2 of the form).[8] If you complete that section, do not submit the filing fee.[9]

Supporting documents. You should include the following documents with your request:

  • A copy of the denial letter from your health insurer; and
  • Any new information and documentation that you had not included with your prior request for an internal appeal.

Submitting a standard external review. If you are requesting a standard external review, you should submit your request to the following address:

David Martini, Esq.
Director External Appeals Program
Vermont Department of Financial Regulation
89 Main Street
Montpelier, VT 05602[10]

Submitting an expedited review. If you are requesting an expedited external review, you should contact the Department at (800) 964-1784 or (802) 828-3302. If it is an emergency, you can contact the External Appeals answering service at (888) 236-5966 after hours.[11]

You must file your written request for an external review within 120 days or four months, whichever is longer, from the date that your insurer sent you the final decision.[12] You should contact Consumer Services at (800) 964-1784 or (802) 828-3302 as soon as possible after receiving an adverse decision from an internal appeal.[13]

The external review process should take no more than 30 days from the date the external review organization receives all the information related to your claim.[14] If you request an expedited external review, the process should take no longer than four business days after your request is received.[15

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

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 name of insurance company;
  • Policy number, claim number, date of loss, date of service, and type of service;
  • The type of coverage;
  • The details of the complaint; and
  • What you consider to be a fair resolution.[16]

Supporting documents. You should submit the following documents as supporting information:

  • 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.[17]

How to submit. The complaint may be submitted online here, faxed to (802) 828-1446, or mailed to the following address:

Consumer Services
Department of Financial Regulation
89 Main Street
Montpelier, VT 05620-3101[18]

The Department will write to your health insurer and request a response. Your insurer must respond immediately upon receipt of the complaint. The Department will also review your complaint and take any necessary actions. The length of the process will depend on how complicated your case is.[19] The Department can require the insurer to reverse its decision depending on the circumstances of your case.

You can contact the Department at (800) 964-1784. The Department is open from 7:45 a.m. to 4:30 p.m. Monday through Friday.