What To Do If A Drug Or Treatment You Want Is Denied Or If You Have Other Complaints Against An HMO
Appeal if you want a drug or treatment or to see a Specialist, and your request is denied. Every HMO has an appeals process for denied requests. Experience shows that persistence pays off. To learn more, see:
For other matters, see: Arguments To Use Against An Insurer's Denial Of A Health Claim.
If appeals within the HMO don't succeed, explore external appeals. To learn more, see below.
Be persistent. Experience shows that persistence pays off.
The more information you can gather to bolster your argument, the better. There are times when the sheer weight of a file can help sway an insurer.
If you need help, get it.
- Contact a non-profit organization that helps. For example:
- If you have a social worker, he or she may be able to help.
- Contact your state's insurance department's ombudsman's office or other office that works with HMO issues. The Kaiser Family Foundation's State Health Facts Online lists resources in each state. www.statehealthfacts.org
- To find an attorney who specializes in insurance issues, speak with your local disease specific non-profit organization, ask a social worker and/or your doctor's office or go tohttp://martindale.com/ .
If appeals within the HMO don’t succeed, explore external appeals.
- If you don’t get what you want after you’ve exhausted the HMO’s appeals procedure, you may have a right to appeal to an external, independent expert or panel of experts.
- Whether there is a right to an external appeal, and if so, the details of the appeal, varies from state to state. The right to an external review exists in almost all states.
- As a general matter, the experts must return a decision within a period of time such as 30 or 45 days. There are provisions for an expedited appeal for matters of life and death.
- In some states, the decision is binding on both parties. In most states, the external decision is only binding on the plan.
- You have a 50% chance of winning on an external appeal. Some HMOs are reversed more than others.
- If you still don’t get what you want, consider complaining to the regulators, consumer organizations and the press and/or going to court or arbitration.
If you still don't get what you want, consider complaining to the regulators, consumer organizations and public opinion. If those ideas don't work, you can go to court or arbitration.
- If apeals do not work, consider complaining to the regulators and see if you can get what you need that way. See Complaining to the Regulators.
- Consider adding other pressure to get the company to say "yes." For instance:
- Involving the local press (television, radio and newspapers) is often a good way to pressure an insurer into doing the right thing. To learn how to get media involved, click here.
- If the HMO has a web site, see if it has a section for members to discuss issues.
- Use social media such as Facebook and Twitter to state your case. Consider a video for You Tube that has a chance of going viral - or at least being noticed by the insurance company.
- Ask your disease specific non-profit organization if there are consumer groups that may take up your cause. Every bit of pressure helps.
- Also consider legal action. You may have a right to sue, even if the policy says you waive the right. To find out whether you do have such a right, consult an attorney.
- Most HMO contracts include a provision that requires any disputes be settled by binding arbitration rather than litigation. In fact, one of the complaints people have about HMOs is that they are required to waive their rights to sue and must use arbitration.
- Arbitration is similar to a court hearing and is often presided over by a retired judge. Sometimes an arbitration happens in front of one arbitrator, sometimes in front of 3 of them. There is no jury. The rules aren't as formal as in a court trial, and there aren't the same restrictions on evidence and testimony. However, the decision by an arbitrator can be as binding as if a court had made the ruling.
- There have been complaints in the past that HMOs created and administered arbitration hearings in such a manner as to heavily favor themselves. However, courts and legislatures have recognized these inequities and many states have set rules that allow for a hearing that is fair.
- Even though arbitration is not a true trial, we do not recommend that you go into an arbitration proceeding without professional help. Consider obtaining the services of an experienced attorney, or at least the guidance of a benefits counselor. At least contact a disease specific non-profit organization for assistance.
- Some arbitration rules do not permit either party to have legal counsel. An attorney can at least help you prepare for the arbitration hearing.
If you have other difficulties with the HMO, file a grievance.
- A Grievance is about misconduct. While it can include a denial of benefits, a grievance is usually used for other problems. For instance, a Grievance may be about the incompetence of a doctor.
- A Grievance generally starts with a complaint with the HMO’s customer service department. You can start a complaint on the telephone. If it isn’t resolved at that level, put it in writing (and keep a copy).
- Most HMOs have a structure in place for appeals of grievances. The next level above the customer service department is often a Grievance Committee composed of representatives from different departments of the HMO.