How to File a Grievance With Your Insurance Company
Dealing with a denial from your health insurance provider can be frustrating, and it can put your health in serious jeopardy when they deny an expensive service you need but can’t afford to pay for on your own. In our experience, insurance companies rarely provide a clear explanation justifying the reason for the denial, leaving policyholders in the dark about how to proceed.
California law gives policyholders the right to challenge such decisions through a formal grievance process that the insurer must provide. Below, we discuss what this process looks like and how it can help you get the care and coverage you need. If you are currently facing a denial of coverage and need help asserting your rights, contact Gianelli & Morris in Los Angeles to review your case with a skilled and experienced California health insurance denial attorney.
What Is a Grievance?
A grievance is a formal complaint you file with your health insurance company when you disagree with a decision they’ve made regarding your coverage. This could pertain to denied claims, delayed services, or any dissatisfaction with the quality of care or service provided. In California, insurers are legally mandated to have a grievance system in place that complies with specific timelines and procedural requirements.
Why Filing a Grievance is Crucial
Consider this scenario:
You’ve been recommended for a medical procedure by your physician. However, your insurance company denies coverage, labeling the procedure as “experimental” or “investigational.” The denial letter references the Evidence of Coverage (EOC) in your policy that says such experimental and investigational procedures aren’t covered, but the letter fails to provide any detailed explanation or cite specific studies or data supporting their classification of this particular procedure as experimental or investigational. To get this information out of the insurer, you have to go further. Filing a grievance is the first step in this process.
A grievance gets you access to more detailed information. Filing a grievance compels the insurer to provide a comprehensive rationale for their decision, often referencing their internal medical policies. For instance, they may have a Medical Policy that states the procedure in question is experimental or investigational. Now you have something solid to go on, because the insurer’s medical policy might be outdated or not applicable to your specific condition. More often than not, insurers rely on their medical policies to issue blanket denials of requested services rather than independently evaluating each individual request as required by law. By initiating a grievance, you have the information you need to contest these inaccuracies.
Also, depending on your insurance company and what type of policy you have, including whether or not it is governed by federal ERISA law, exhausting the insurer’s grievance process might be a necessary step before pursuing legal remedies such as filing a lawsuit in court.
Anthem Blue Cross: A Case Study
Anthem Blue Cross, one of California’s major health insurers, has faced scrutiny over its grievance-handling practices. In December 2024, the California Department of Managed Health Care (DMHC) fined Anthem $3.5 million for failing to address over 10,000 member complaints in a timely manner between July 2020 and September 2022. The investigation revealed that Anthem delayed acknowledgment and resolution letters, with some acknowledgments being more than 51 days late and others not sent at all.
This wasn’t an isolated incident. In 2017, Anthem was fined $5 million for systemic violations in its grievance system, including failure to identify and resolve enrollees’ grievances promptly. At the time this fine was announced, DMHC noted Anthem had racked up $11.66 million in penalties for grievance system violations since 2002. These repeated infractions, which continue to this day, highlight the importance of policyholders being proactive and informed when pursuing a grievance.
Steps to File a Grievance with Anthem Blue Cross
Below are the procedures for filing a grievance with Anthem. If you have a different insurer, the steps are likely to be the same or substantially similar, as the legal timelines noted below are set in state law and apply to all insurance companies doing business in California.
- Identify the Issue: Clearly define the problem, whether it’s a denied claim, delayed service, or dissatisfaction with care.
- Gather Documentation: Collect all relevant documents, including denial letters, medical records, and any correspondence with the insurer.
- Submit the Grievance:
- Online: Log in to your Anthem account and use the online grievance form.
- Phone: Call Anthem’s Member Services at the number on your membership card.
- Mail: Send your grievance to the address provided in your policy documents.
Members have up to 180 calendar days from the date of the incident or denial to submit a grievance.
- Await Response: Anthem is required to acknowledge receipt of your grievance within five calendar days and provide a written decision within 30 calendar days.
What to Expect After Filing
Upon reviewing your grievance, Anthem should provide:
- Detailed Explanation: A clear rationale for their decision, referencing specific policy provisions and medical guidelines.
- Information on Further Rights: Guidance on additional steps you can take if dissatisfied, such as requesting an Independent Medical Review (IMR) or seeking assistance from the DMHC.
If the response lacks clarity or fails to address your concerns adequately, you may consider escalating the matter.
Independent Medical Review and Legal Action
If your grievance doesn’t yield a satisfactory resolution, you can request an IMR through the DMHC. An IMR involves an external review by medical professionals who assess the medical necessity of the denied service.
Should the IMR uphold the denial, or if the insurer fails to comply with grievance procedures, legal action might be warranted. Consulting with an experienced insurance law attorney can help you navigate this complex process and advocate for your rights.
Insurance Claim Denied in California? Contact Gianelli & Morris for Help
Filing a grievance is not only a step toward resolving your current issue but also often a prerequisite for pursuing legal action if necessary. It ensures that you’ve exhausted internal remedies and provides documentation that can be crucial in court.
If you believe your insurer has acted in bad faith, consulting with an attorney experienced in insurance law can help you know where you stand and advocate for your rights in and out of court. In California, contact Gianelli & Morris for a free consultation to review your situation and understand your options.
