When Health Plans Violate Timely Access to Care Laws in California

Health insurance denials do not always come in the form of a written refusal. Sometimes the most damaging conduct is delay. A postponed authorization. A referral that sits unprocessed. A surgery cancelled days before it was scheduled. A specialist appointment pushed out for months.

Under California law, timely access to care is not optional. It is a statutory requirement. When health plans fail to provide timely access to medically necessary services, they may be violating the law, and in certain cases, they may be exposing themselves to civil liability.

If your request for medical treatment has been unreasonably delayed or denied, contact Gianelli & Morris to share what happened with a team of skilled and experienced California insurance bad faith attorneys.

California’s Timely Access to Care Requirements

California’s health plans are regulated under the Knox-Keene Health Care Service Plan Act. Among its consumer protections are specific mandates requiring plans to ensure that enrollees receive timely access to covered health services.

Health and Safety Code section 1367.03 requires health care service plans to provide or arrange for the provision of covered services in a timely manner appropriate for the enrollee’s condition. The Department of Managed Health Care (DMHC) has adopted detailed regulations implementing this mandate, including maximum appointment wait times for:

• Urgent care appointments
• Non-urgent primary care visits
• Non-urgent specialist visits
• Ancillary services such as laboratory testing and imaging

For example, non-urgent appointments with specialists generally must be available within 15 business days of the request. Urgent care appointments must be provided within much shorter timeframes, depending on whether prior authorization is required.

These are not aspirational guidelines. They are enforceable regulatory standards.

How Delays Occur in Practice

Despite these legal requirements, delays remain common. They often arise through systemic mechanisms rather than explicit denials.

One frequent source of delay is the prior authorization process. A physician submits a request for approval of imaging, surgery, durable medical equipment, or specialty treatment. The request is “pended” for additional information. Then it is reviewed by a utilization management nurse. Then escalated to a medical director. Then returned for clarification. Each step adds days—or weeks.

Another mechanism involves referral bottlenecks within HMO structures. A primary care physician must act as a gatekeeper, approving referrals to specialists. If the referral is not promptly issued, or if the medical group claims no specialist is available within the network, the patient may wait months for care.

In some cases, the health plan and the delegated medical group point fingers at each other while the subscriber remains untreated. Meanwhile, symptoms worsen.

When Delay Becomes a Legal Violation

Not every scheduling issue constitutes a legal violation. However, delays may cross the line when:

• Appointment wait times exceed regulatory standards without a valid exception;
• Authorization decisions are not made within required statutory timeframes;
• The plan fails to arrange out-of-network care when no in-network provider is available within timely access standards;
• Administrative inefficiencies cause repeated postponement of medically necessary treatment;
• The delay results in deterioration of the patient’s condition.

California law requires plans to monitor and ensure compliance with timely access regulations. They cannot shift responsibility entirely to contracted medical groups.

If a health plan’s systems are structured in a way that routinely causes delays beyond regulatory timeframes, that may reflect a systemic compliance failure rather than an isolated scheduling error.

The Medical Consequences of Delay

Timely access laws exist because delay has real medical consequences.

For a patient awaiting cancer surgery, delay may allow tumor progression. For a patient needing cardiac intervention, delay can increase the risk of a heart attack. For someone requiring orthopedic surgery, delay can prolong severe pain and functional impairment.

Even in less acute cases, prolonged suffering and reduced quality of life are not trivial harms. The law recognizes that access to medically necessary care must be meaningful, not theoretical. A health plan cannot technically “approve” care while functionally preventing access through scheduling barriers or administrative inertia.

Regulatory Enforcement vs. Civil Remedies

The DMHC has authority to investigate and penalize health plans that violate timely access requirements. Enforcement actions may result in corrective action plans and financial penalties. However, regulatory fines are paid to the state. They do not compensate the individual enrollee who experienced harm from the delay.

When a delay in care is unreasonable and causes injury, policyholders may have civil remedies. Under California law, insurers owe a duty of good faith and fair dealing. This includes the obligation to process claims and authorization requests fairly and without unreasonable delay. An unreasonable delay in approving or arranging medically necessary care can support a bad faith claim if it reflects a failure to give equal consideration to the insured’s interests.

In certain cases, damages may include:

• Additional medical expenses caused by the delay;
• Worsening of the underlying condition;
• Emotional distress;
• In appropriate circumstances, punitive damages.

These cases are highly fact-specific and require detailed analysis of medical records, authorization logs, internal communications, and regulatory standards.

Why Timely Access Cases Are Complex

Timely access violations are often more difficult to litigate than straightforward denials.

First, the harm may be incremental rather than immediate. A plan may argue that treatment was eventually provided, even if delayed. Demonstrating medical causation (showing that the delay caused measurable harm) frequently requires expert testimony.

Second, health plans often rely on delegation agreements with medical groups. Determining whether the plan, the medical group, or both bear legal responsibility requires a sophisticated understanding of regulatory delegation structures.

Third, insurers typically maintain extensive documentation systems. Identifying gaps, missed deadlines, or systemic bottlenecks requires careful forensic review.

These are not cases that can be evaluated based solely on a denial letter. They demand a comprehensive investigation.

Protecting Your Rights When Care Is Delayed

If you are experiencing prolonged delays in accessing medically necessary treatment, several steps are important:

• Document every request for authorization or referral, including dates.
• Request written explanations for delays.
• File a formal grievance with the health plan.
• Escalate to an independent medical review when appropriate.

Creating a documented timeline is critical. Regulatory timeframes are measured in days, and compliance often turns on precise chronology. Most importantly, do not assume that delay is simply part of the system. California law was designed to prevent exactly that.

Statewide Representation for California Policyholders

At Gianelli & Morris, we represent policyholders across California who have suffered harm due to wrongful denials and unreasonable delays in care. We serve clients throughout Los Angeles, San Diego, San Francisco, Sacramento, San Jose, Fresno, Oakland, and surrounding communities. We analyze whether a health plan complied with statutory timely access requirements, whether delegation structures were properly supervised, and whether delays rise to the level of bad faith.

When medically necessary care is postponed without justification, the consequences can be severe. Health plans are required by law to ensure timely access—not merely eventual access. If your treatment has been delayed beyond what is medically reasonable, you may have more options than you realize. Contact Gianelli & Morris to discuss your matter with our dedicated California insurance bad faith attorneys.