You asked for information on the health insurance claim appeal process.

SUMMARY

If a person wants to appeal a decision by an insurer who denied coverage under a health insurance policy, he may use the insurer's internal grievance process. The insurer must send information about how to appeal a denial with the denial notice. If all or part of the denial is upheld on appeal, the person may initiate an external appeal, which involves the Connecticut Insurance Department.

APPEALS

Managed care organizations (MCO) and health insurers must (1) have a grievance process for enrollees to appeal the entity's actions or inactions and (2) notify enrollees of the process at initial enrollment, annually thereafter, and when denying a service, admission, or hospital stay extension (CGS § 38a-478m). Many MCO's and insurer's employ or consult with medical professionals (e. g. , nurses and doctors) who assist in appeal reviews and determinations.

After exhausting the internal grievance process, a plan enrollee may appeal an MCO's or health insurer's denial to the insurance commissioner (CGS § 38a-478n). The MCO or health insurer must send the enrollee procedures and an application for filing an appeal with the commissioner (referred to as an “external appeal”). Information on external appeals, including a consumer guide (copy enclosed), is available on the insurance department's web site, www. ct. gov/cid/cwp/view. asp?a=1267&q=254468.

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