State help is availableIf you feel you're in over your head, if your appeal is denied or if your plan does not respond in a timely fashion, contact your state's department of insurance (in some states known as the department of managed care).
Every state has different ways of assisting consumers with health insurance appeals. The Kaiser Family Foundation provides information on every state's health care rules.
1. Certain states mandate certain types of coverage. Check the mandates for your state. The benefits you seek may be mandated, even if they are not dictated specifically in your policy.
2. Some states have an ombudsman who can provide detailed guidance through the process. Some have special offices for HMO issues. Some have only administrative assistance, taking the complaint and investigating. Your state's department of insurance will be able to tell you exactly how much assistance they can provide. Be sure to ask, and take advantage of all that is there.
3. If you have been denied coverage due to a perceived lack of medical necessity or because your insurance company considers your coverage experimental or investigational, most states now allow you to apply for an independent external review. Your state's department of insurance will be able to inform you if your state is one of these. This review will allow for an appeal of your case by an independent panel of physicians. While statistics vary by state, you have about a 50-50 chance that the review board will decide in your favor.
There is one notable exception to many of the provisions stated here. If you work for a large employer, you may be covered by a self-funded plan in which the employer is actually paying your claims and merely using the insurance company for administrative purposes.
Your company's human resource department should be able to tell you if your plan is self-funded. Self-funded plans are not subject to state regulation. Therefore, if you need to appeal to a higher authority, you need to go to federal agencies, not state.
Contact the Department of Labor's Pension and Welfare Benefits Administration, and they will consider your appeal. You have a chance of winning on appeal, especially if they find that the decision in your case was inconsistent with decisions made for other plan members.