Consumer Guide: Problems with Health Insurance

There are many types of health insurance plans. You may have an issue with your plan if:

• Your claim gets denied.
• You can’t get your plan to pay for your care.
• You can’t get the care you need.

File a complaint against your health insurance plan

If you have problems with your health insurance plan, you should speak up. There are some steps you can take to resolve an issue.

Make sure you know what your health insurance plan covers

Your type of health insurance plan affects what you do to solve the issue.

• Is your health insurance through your employer AND does your employer self-insure your plan? If yes, your plan must follow federal Employee Retirement Income Security Act laws. The plan does not have to follow state insurance laws. This means steps 1–6 (below) apply to you, but you can’t work through the Office of the Commissioner of Insurance. Learn more about the laws that apply to your plan (PDF).
• Do you work for the state? If yes, steps 1–6 (below) apply to you. You also can contact an ombudsperson at the Department of Employee Trust Funds. This person looks at your complaint. They may be able to help resolve the issue. Learn more about ombudsperson services.
• Are you part of Medicaid or BadgerCare Plus with a managed care plan? If yes, you can contact either your plan or the Division of Medicaid Services. They are part of Wisconsin Department of Health Services (DHS), which runs Medicaid and BadgerCare Plus. These plans have a person whose job is to help you.
• Are you part of Medicaid with a fee-for-service plan? If yes, you can contact the Division of Medicaid Services. They are part of DHS, which runs Medicaid.
• Do you have Medicare? If yes, CMS (Centers for Medicare & Medicaid Services) has information on appeals and grievances. They also list contacts to help you resolve the issue.

Follow the steps to resolve your insurance complaint

If you have the right health insurance plan, follow these steps:

1. Call your plan’s customer service and explain your issue or concern.
   • Write down who you talk to. Note their name, title, the date, and what you talked about.
   • If they make a promise, ask for it in writing. You also can ask for them to record the call.
2. If your issue is fixed by phone, great! You can stop here. If you still have concerns, you need to send them in writing.
3. Write down your concern and send it to your plan.
   • If a delay in response could risk your life or health, send your concern in writing right away. Fax it instead of mailing it. You and your plan will then complete what’s called an expedited grievance process. Your plan must resolve this type of grievance within 72 hours after they get your request in writing.
   • If there is no risk to your life or health, write to your plan about your concern. This is called filing a grievance. In the letter, describe your problem, what you’ve done to solve it, and how you’d like the problem resolved. Include copies of any documents you have from your doctor or other provider. Make copies of anything you get. Your plan must, by law, follow certain steps for your grievance. See steps 4–6.
4. Get notified within five business days that your plan has received your grievance. They’ll likely tell you when their grievance committee meets next. They must tell you, in writing, when and where the next meeting will happen at least seven days before they meet.
5. Decide to attend the grievance committee meeting or not.
   • You have the right to go to the meeting. If you go, you can bring anyone with you. This includes family, friends, a doctor, or a lawyer. You’ll have a chance to explain your concern in person and answer any questions.
   • You can choose not to go to the meeting. If you choose not to go, the committee will decide based on what you sent in writing.
6. Receive a decision on your grievance. The committee often tells you what they decide soon after the grievance committee meeting. They have up to 30 calendar days after getting your grievance to resolve it. They can delay for another 30 days if they think they need more information. If they delay a decision, they must let you know the reason for the delay in writing. They also must tell you when you can expect the decision.

Review other actions you can take

Along with filing a grievance with your plan, you can:

• File a grievance with the Office of the Commissioner of Insurance—You may file a complaint by phone, mail, or online. Visit the Office of the Commissioner of Insurance website for more about filing an insurance complaint.
• Fight your case in small claims court—This is an option if you don’t agree with what your plan or the Office of the Commissioner decides about your grievance.
• Contact a lawyer—You can do this at any point during the grievance process. A lawyer may be able to work with your plan without filing a lawsuit. Many people try to avoid lawsuits because they can cost a lot and cause stress. They also don’t promise the results you want.

Related topics

• Complaints or Problems with Your Health Care
• Problems with Health Care Providers
• Problems with Medical Bills or Debt