Appeal of Insurance Denial

You asked what appeal options an insurance applicant has when, after exhausting internal appeal processes, a managed care organization (MCO) declines to issue him an individual managed care insurance policy.

A person can file a complaint with the Connecticut Insurance Department’s Consumer Affairs Division when a MCO turns him down for coverage. He can file a complaint whether or not he has used the MCO’s internal appeal process.

The Consumer Affairs Division requires that a person send concerns or complaints in writing to the following address: State of Connecticut Insurance Department, Consumer Affairs, P. O. Box 816, Hartford, CT 06142-0816.

The information sent to the department should be as complete as possible. It should describe the situation and include the (1) person’s name, address, and telephone number; (2) insurance company’s name; (3) type of policy; and (4) policy and claim numbers, if applicable. A complaint form can be downloaded from the insurance department’s web site at www. ct. gov/cid. A copy is also enclosed.

The examiner assigned to the complaint will send an acknowledgement that he has received and is reviewing it. At the same time, he will send a copy of the complaint to the MCO to obtain their response to it. After a response is received from the MCO, the examiner will determine how best to resolve the complaint.

It appears that the external appeal process provided by CGS § 38a-478n is not applicable to this situation. The external appeal process is available to contest a “utilization review” decision. Utilization review (UR) is the prospective or concurrent assessment and decision-making process used to determine the medical necessity of a medical treatment or service. A person is eligible to use to the external appeals process if:

• he is an enrollee in a managed care plan at the time the medical service is requested;

• he has exhausted the internal appeal process of the MCO or the UR company acting on behalf of the MCO;

• he, or a provider on his behalf, submits (1) a request for external appeal to the insurance department within 30 days of receiving a final determination from the MCO or UR company; (2) a $ 25 filing fee, unless the insurance commissioner determines that the enrollee is indigent; and (3) a release for relevant medical records;

• the medical service requested is a covered service under the managed care plan;

• the UR determination was based on medical necessity;

• the appeal is not for a workers’ compensation claim;

• the managed care plan is underwritten by a MCO (i. e. , is not “self-insured” by the employer); and

• the managed care plan is not Medicaid or Medicare.

Additional information regarding the external appeals process can be found on the Connecticut Insurance Department’s web site.


March 30, 2004		2004-R-0340
APPEAL OF INSURANCE DENIAL

By: Janet Brierton, Associate Legislative Attorney