California Health Insurance Appeal Lawyer

Under California law, you can usually challenge a denied health insurance claim through your plan's grievance process first and then through Independent Medical Review (IMR). For plans regulated by the Department of Managed Health Care, the IMR application is ordinarily due within six months of the plan's written grievance response under Cal. Health & Safety Code § 1374.30. The DMHC can accept a later application for good cause.

Your health plan may have refused a surgery, a medication, or a bill for care you already received. That leaves two practical questions: how to appeal, and when a lawyer is worth calling. Gianelli & Morris has spent 40+ years serving California policyholders and represents people only against insurance companies. Partner Robert S. Gianelli represents policyholders in health, life, disability, and property insurance disputes from our Los Angeles office. This page covers California's appeal routes, the deadlines that run alongside them, and when a denial may support a bad-faith lawsuit.

Robert S. Gianelli is a Los Angeles partner who takes on health plans and insurers that refuse care their members are counting on. His work on Arce v. Kaiser, a class action over denied autism treatment, earned him the California Lawyer Attorney of the Year (CLAY) Award. For insurance bad faith cases, we work on contingency, so our fees come as a percentage of any award we recover. Call 213-489-1600 for a free consultation to discuss your legal options.

Key Takeaways

• California HMO and other DMHC-regulated plans must resolve a member grievance within 30 days, or within 72 hours when the member's health faces an imminent and serious threat.
• When the DMHC adopts an IMR decision finding care medically necessary, the plan has five working days to authorize the service or to reimburse care already provided (Health & Safety Code § 1374.34).
• Insurance Code § 790.03 does not let policyholders sue directly. The lawsuit is a common-law bad-faith claim, and § 790.03 serves as evidence of reasonable claims handling.
• California courts generally apply a two-year period to bad-faith tort claims and a four-year period to claims on the written policy. Policy clauses, accrual, and tolling can shorten or shift those periods.
• Private-employer group plans governed by ERISA generally don't allow bad-faith tort, punitive, or emotional-distress damages. Government and church plans are exempt from ERISA.

What Is at Stake After a California Health Plan Denies Care?

A health insurance denial is rarely just a billing problem. In California, the plan grievance, the Independent Medical Review window, and the deadline to sue can all run at once, and missing one can close a route that would otherwise have stayed open. Meanwhile, the treatment you need is on hold or on your credit card.

Most people focus on the medical problem first, which makes sense. But the denial letter also starts several clocks, and each one is governed by a different law.

The deadlines that start with a denial

Here's what can be running at the same moment:

• The plan grievance. In a DMHC-regulated plan, the plan has 30 days to resolve your grievance. It has 72 hours when your health faces an imminent and serious threat.
• The IMR window. The application is ordinarily due within six months of the plan's written response to your grievance. It does not run from the original denial, and the DMHC can accept late applications for good cause.
• The lawsuit deadline. California courts commonly measure the time to sue from the insurer's unequivocal denial. The policy itself may contain a shorter suit clause.

None of these clocks waits for the others. A person who spends a year trading letters with customer service may reach IMR on time and still lose ground on a later lawsuit.

What a successful appeal fixes, and what it leaves unresolved

Winning an IMR does real work. Under Cal. Health & Safety Code § 1374.34, once the DMHC adopts a decision that a service is medically necessary, the plan must authorize care not yet provided within five working days. For care already provided, it must reimburse the provider or the enrollee within five working days.

But there's a catch.

An IMR decision does not compensate you for pain, a worsened condition, lost income, or other harm caused by the delay. Those losses belong to a separate legal question: whether the insurer handled your claim in bad faith.

Take a hypothetical. A Los Angeles member's request for spinal surgery is denied as not medically necessary in March. She files a grievance, loses, and then wins IMR in the fall. The plan now has to authorize the surgery. The months of worsening symptoms and missed work fall outside the IMR decision, though they may be part of a later bad-faith claim. That gap is why the appeal and any possible lawsuit should be planned together from the start.

Which Appeal Path Fits Your Plan: DMHC, Department of Insurance, or ERISA?

Your appeal rights in California depend on who regulates your coverage, not on which company's logo appears on your card. HMOs and most managed-care plans are governed by the Knox-Keene Health Care Service Plan Act and regulated by the California Department of Managed Health Care (DMHC). Health insurance policies regulated by the California Department of Insurance (CDI) follow the Insurance Code instead. Private-employer plans add a federal layer under ERISA.

ERISA is the Employee Retirement Income Security Act, the federal law that governs most benefit plans sponsored by private employers. It sets claims procedures for those plans and, through its preemption provision (29 U.S.C. § 1144), displaces many state-law remedies.

How to tell who regulates your coverage

Start with your Evidence of Coverage, the document a health plan issues that sets out covered benefits, exclusions, and the grievance procedure. Insurance policies have a policy certificate that plays the same role. Your ID card, your denial letter, and your plan's grievance notice usually name the regulator. HMO coverage is DMHC-regulated. PPO coverage may fall under either agency, so check the paperwork before assuming.

Why employer plans get screened first

Gianelli & Morris does not handle ERISA-governed employee benefit cases. If your coverage comes through a private employer, we'll tell you so at the start and explain why your rights work differently. That isn't the end of your options. If the employer plan is insured, for example a Kaiser HMO offered through a private company, you keep the Knox-Keene grievance and DMHC IMR rights even though ERISA controls what a lawsuit can recover. Only self-funded employer plans fall entirely outside the DMHC. The U.S. Department of Labor (EBSA) handles questions about federal claim rules for employer plans.

Government and church plans

Plans for public employees and church workers are exempt from ERISA. People covered by those plans generally retain California bad-faith remedies against the insurer, though the plan's structure and the identity of the defendant can matter. We cover this in more depth on our page about how public employee insurance denials are different.

How Does Independent Medical Review in California Work?

Independent Medical Review is a state-run process in which physicians who don't work for your plan decide whether denied care is medically necessary. Under Health & Safety Code § 1374.30, IMR covers DMHC-plan decisions that deny, modify, or delay services as not medically necessary, and the enrollee can't be charged a fee to apply. IMR also covers certain experimental and emergency-care disputes. CDI-regulated policies have their own IMR system.

Two other terms come up at every stage. Utilization review is the process a plan uses to approve, modify, delay, or deny requested care based on medical necessity. A grievance is your written complaint to the plan asking it to reconsider. Every health plan must keep a DMHC-approved grievance system and tell members how to use it under Cal. Health & Safety Code § 1368.

Do you have to file a grievance before IMR?

Do you have to file a grievance before applying for IMR? Usually, yes. For a medical-necessity IMR, the enrollee must first file a grievance with the plan. You don't have to stay in that process for more than 30 days, or three days when the case is expedited. In extraordinary and compelling cases, the DMHC may waive the grievance requirement under Cal. Health & Safety Code § 1374.31.

Our article on the health insurance grievance system California law requires explains what a plan's grievance process has to include. You can file through the DMHC's Independent Medical Review application. If you're curious how these reviews tend to come out, our discussion of DMHC Independent Medical Review data is a good next read.

Experimental treatment and CDI-regulated policies

Some denials follow a different track. When a plan refuses an experimental or investigational therapy for a member with a life-threatening or seriously debilitating condition, the Knox-Keene Act requires a separate external, independent review if the member meets the statute's criteria. Members of health insurance policies regulated by the Department of Insurance use the CDI's own IMR system under Cal. Ins. Code § 10169.

Medi-Cal members in managed-care plans

Medi-Cal members enrolled in a Knox-Keene plan aren't excluded from IMR. Medi-Cal also has its own appeal path, though, and the order matters. The member first appeals to the plan within 60 days of the Notice of Action, and the plan decides within 30 days, or 72 hours when expedited. If the plan upholds the denial, the member has 120 days from the plan's Notice of Appeal Resolution to request a Medi-Cal state fair hearing. To keep benefits in place during the dispute (called aid paid pending), the member must ask within 10 days of the notice or before its effective date. Confirm how IMR fits with the fair hearing before filing either.

How Long Does a Health Insurer Have to Decide a Claim or Appeal?

The answer depends on which law governs your plan, and the different clocks shouldn't be combined. For DMHC-regulated plans, a grievance must be resolved within 30 days, or 72 hours when expedited. For CDI-regulated health policies, the insurer must pay a complete claim or explain in writing why it's contesting or denying it within 30 calendar days under Cal. Ins. Code § 10123.13. ERISA plans follow a separate federal schedule.

State-regulated plans and policies

A Knox-Keene plan's utilization-review decisions come first. Under Cal. Health & Safety Code § 1367.01, routine prospective requests must be decided within five business days of receiving the information reasonably needed, and urgent requests within 72 hours. Only a licensed physician or a competent licensed health care professional may deny or modify a request for medical-necessity reasons. The denial must be in writing and must include the criteria used and the clinical reasons.

Section 10123.13 sets a 30-calendar-day rule for paying or contesting a complete claim. The 40-day accept-or-deny rule found in California's fair claims regulations doesn't apply to health insurance claims covered by § 10123.13.

ERISA employer plans

Federal regulation 29 C.F.R. § 2560.503-1 sets minimum claims procedures for every ERISA plan, whether insured or self-funded. ERISA itself requires written notice of a denial with specific reasons and a fair opportunity for review (29 U.S.C. § 1133).

Group health plans must give claimants at least 180 days after receiving a denial to file the internal appeal. An insured employer plan has to meet both the federal schedule and California's Knox-Keene or Insurance Code deadlines. Only self-funded plans follow the federal schedule alone. For more on appeal response times, see how long an insurance company has to respond to an appeal.

What if the plan misses its deadline? For a DMHC plan, once 30 days pass without a resolution (three days if expedited), you can move to IMR without waiting further. A missed deadline also becomes part of the record if the claim later turns into a bad-faith dispute.

Gate, Record, Remedy: How We Evaluate a Denied Health Insurance Claim

When a California policyholder brings us a denial, we take it through a six-step framework we call Gate, Record, Remedy. The framework settles which law governs, locks down every running deadline, tests the denial against California's utilization-review and claims-handling standards, and then weighs administrative review against litigation. It's a way of sequencing decisions. It is not a prediction of any result.

Step 1: Identify the governing path

Who sponsors and regulates the coverage shapes everything after it. A private-employer group plan points toward ERISA, and we screen those matters out and explain why. A Knox-Keene plan follows the DMHC grievance and IMR route. A CDI-regulated policy follows the Insurance Code route. If the answer isn't clear, we resolve it before taking any other step.

Documents: Evidence of Coverage or policy, enrollment and premium records, any employer plan documents, insurance ID card.

Step 2: Lock down the clock

We read the policy's suit-limitation clause and note every denial date that could start a deadline. If any deadline is close, preserving the claim comes before refining strategy. When it's unclear whether a denial was final, we treat that as an open question for counsel to resolve, not something to assume.

Documents: All denial and appeal letters with their dates, the policy's suit clause, grievance correspondence.

Step 3: Take the denial letter apart

We check who made the decision, what criteria were cited, what clinical reasons were given, and whether the decision arrived on time. A non-clinician reviewer, missing criteria, boilerplate reasons, or a late decision can strengthen the administrative appeal. The same gaps can also support a later claim that the insurer acted unreasonably. If the letter is complete on its face, the focus moves to the medical merits.

Documents: Denial letter, the utilization-review criteria cited, the reviewer's identity and credentials, a timeline of the claim and authorization.

Step 4: Choose the review route

For DMHC plans, that means a grievance and then IMR. For CDI policies, it means the Insurance Code process and the CDI's IMR. When the client's condition is urgent, we request expedited handling. We build the submission around the treating physician's evidence and any California coverage mandate that applies. Our article on writing an appeal letter for a health insurance denial covers the medical-necessity letter in more detail.

Documents: Treating physician's letter of medical necessity, medical records, peer-reviewed literature, grievance filings.

Step 5: Test the insurer's investigation

Did the insurer actually investigate, or did it reach a conclusion first and look for support afterward? We request the claim file and reviewer notes and compare them with the medical record. Any arbitration clause gets checked here too, because it affects where a claim can be heard.

Documents: Complete claim file, internal guidelines applied, communications log, arbitration provision.

Step 6: Match the remedy and the scale

Finally, we compare three options: an individual appeal, an individual lawsuit, and a broader challenge to a practice. If a denial reflects a uniform rule, such as a blanket exclusion or misapplied criteria, it's worth asking whether other members face the same problem. The right choice depends on the strength of the evidence, how urgent the medical need is, and whether the denial pattern repeats.

Documents: Out-of-pocket and fee records, evidence of a uniform denial policy, a damages summary.

Talk through your denial with us. Bring your denial letter and Evidence of Coverage, and we'll walk through which path applies and which deadlines are already running. Call Gianelli & Morris at 213-489-1600 for a no-cost case review.

When Does a Health Insurance Denial Become Bad Faith in California?

A denial isn't bad faith just because it's wrong. California law implies a covenant of good faith and fair dealing in every insurance policy, and an insurer that unreasonably withholds benefits from its own insured can be liable in tort (Gruenberg v. Aetna Ins. Co. (1973) 9 Cal.3d 566). An honest, reasonable disagreement over coverage usually doesn't meet that standard.

The implied covenant of good faith and fair dealing is a duty the law places on every insurer to deal fairly with its policyholders and not to frustrate their right to receive benefits. It exists whether or not the policy mentions it. You can read more in our discussion of Gruenberg v. Aetna.

The genuine dispute defense and its limits

Insurers often argue that a genuine dispute existed, meaning a reasonable, good-faith disagreement over whether the claim was covered. The California Supreme Court held that this defense protects an insurer only when its position rests on a reasonable, good-faith investigation. In Wilson v. 21st Century Ins. Co. (2007) 42 Cal.4th 713, the court ruled that a jury could find bad faith where the insurer reached a medical conclusion without fairly investigating and disregarded the treating physician's evidence.

That holding matters for health denials. The Knox-Keene Act's own statement of purpose includes keeping the health professional as the determiner of the patient's health needs.

Why you can't sue under Insurance Code § 790.03

Cal. Ins. Code § 790.03 lists unfair claims settlement practices, but it gives policyholders no private right of action (Moradi-Shalal v. Fireman's Fund Ins. Cos. (1988) 46 Cal.3d 287). The Department of Insurance enforces it. The lawsuit itself is a common-law bad-faith claim, and § 790.03's standards serve as evidence of what reasonable claims handling looks like. Our page on California Insurance Code 790.03 and bad faith covers this further.

Denial types that raise specific legal questions

• Medical necessity. For most care, the plan's Evidence of Coverage supplies the working definition. Mental health and substance use disorder treatment in DMHC-regulated plans is the exception: California law defines medically necessary treatment for those conditions in the statute itself, which affects cases like residential treatment denials.
• Emergency care. Under Cal. Health & Safety Code § 1371.4, plans must reimburse emergency services and care until the patient is stabilized. See our article on emergency room claim denials.
• Continuity of care. When your doctor leaves the network, Cal. Health & Safety Code § 1373.96 can let you finish covered treatment with that provider for certain conditions, if you ask.
• Rescission. A plan that cancels coverage back to its start date raises separate questions, covered on our page about bad faith rescission of a health insurance policy.

What Can You Recover if You Sue Your Health Insurer?

In a non-ERISA California bad-faith case, recoverable damages can extend well beyond the denied benefit. Attorney fees you reasonably incur to obtain benefits the insurer tortiously withheld are recoverable as damages (Brandt v. Superior Court (1985) 37 Cal.3d 813), but fees spent pursuing the bad-faith claim itself are not. ERISA-governed employer plans don't allow these tort remedies.

Brandt fees are the portion of your attorney fees that went toward getting the contract benefits paid. They're treated as part of the harm the insurer caused.

Punitive damages are never assumed

California's punitive damages statute allows them in a tort case only on clear and convincing evidence of oppression, fraud, or malice. That's a demanding standard, and no responsible lawyer builds a case on the assumption it will be met. Our page on remedies for bad faith insurance practices goes into more detail.

The ERISA limit, stated precisely

Under 29 U.S.C. § 1132, a participant can sue to recover plan benefits under § 1132(a)(1)(B). Recovery is generally limited to the benefit plus potential interest, attorney fees under § 1132(g), and appropriate equitable relief under § 1132(a)(3). There's no bad-faith tort, no punitive damages, and no emotional-distress damages. ERISA benefit suits can be filed in either state or federal court.

How Long Do You Have to Sue a Health Insurer in California?

There isn't one universal deadline. California courts generally apply the two-year period of Cal. Code Civ. Proc. § 339(1) to bad-faith tort claims (Love v. Fire Ins. Exchange (1990) 221 Cal.App.3d 1136) and the four-year period of Cal. Code Civ. Proc. § 337(a) to claims on the written policy. Both commonly run from the insurer's unequivocal denial. Accrual rules, tolling, and contractual limitation clauses in the policy can shorten or shift either period.

The policy's own suit clause

Health insurance policies regulated by the Department of Insurance must contain a legal-actions provision under Cal. Ins. Code § 10350.11. It bars suit before 60 days after written proof of loss and after three years from the time proof of loss is required. Policy language varies. In one published decision, an insurer's own clause gave the insured three years to sue for breach of the implied covenant.

Why the start date is the hard part

People often think the clock starts the day the first denial letter arrives. Sometimes it does. When a plan keeps reconsidering, asks for more records, or partly pays, though, identifying the controlling date takes a careful read of the whole file. The safest approach is to have counsel calculate your specific deadlines early rather than relying on a general rule.

Health Coverage Cases Our Firm Has Litigated

Gianelli & Morris has brought class actions that required major health plans to cover care they had refused, including reconstructive surgery, prosthetic limbs, autism treatment, and residential mental health treatment. These cases show why a single denial is sometimes worth testing as a broader practice. Past results describe our experience. They don't predict the outcome of any future matter.

What LaRue illustrates

In LaRue, Robert S. Gianelli and co-counsel Rene Kern of the Kern Law Group tried the case for Terry LaRue, a Health Net member on an Affordable Care Act plan. The jury returned its verdict against Accountable Health Care, IPA, the medical group Health Net contracted with, for failing to provide a timely surgical referral. The case shows that delay, and not only outright denial, can cause legal harm. We have recovered Hundreds of Millions of Dollars.

Why patterns matter

A denial built on a uniform rule affects every member that rule touches. When the same exclusion or criteria show up across many members, a class case may be possible. Our article on a class action over denial of necessary medical treatment gives one example.

Los Angeles County Courts, Arbitration, and Agencies in Health Coverage Disputes

Civil insurance lawsuits in Los Angeles County are filed in the Los Angeles County Superior Court, and your case notice and assigned department control where the case is heard. An individual health insurance bad-faith case is ordinarily an unlimited civil case, the Superior Court category for claims above the limited-civil dollar cap. It isn't designated a complex case, which is a separate status under the California Rules of Court. You can find general court resources through California Courts.

When a case moves to federal court

An insurer sued in Los Angeles may try to remove the case to the U.S. District Court for the Central District of California. Removal based on diversity requires more than $75,000 in controversy. Because a corporation is a citizen both of every state where it's incorporated and of the state where it has its principal place of business, an insurer sued by a California resident can remove on diversity only if it is both incorporated and headquartered outside California.

Arbitration clauses in health plan contracts

Some health plan contracts require binding arbitration. When a neutral arbitrator is proposed, Cal. Code Civ. Proc. § 1281.91 generally allows a party to seek disqualification within 15 calendar days of the arbitrator's disclosure, and one court-appointed arbitrator may be disqualified without cause. Some health plan arbitration clauses may also be subject to additional state oversight; consult current law for the latest requirements. Arbitration clauses do not eliminate the ability to seek other remedies where applicable.

The state agencies involved

The DMHC handles grievances, IMR, and enforcement for Knox-Keene plans. Our pages on the role of the DMHC in health insurance denials and the DMHC complaint process explain how it works. The DMHC's enforcement activity is a matter of public record. The DMHC publishes enforcement actions, including penalties against health plans, on its public enforcement records. For CDI-regulated policies, the Department of Insurance consumer help line accepts requests for assistance.

What Does a Health Insurance Claim Lawyer Cost, and What Should You Bring?

At Gianelli & Morris, we take insurance bad faith cases on a contingency fee basis, which means our fees are taken as a percentage of any award we recover. Grievances, IMR applications, and Medi-Cal appeals are administrative matters. We explain the fee arrangement for those at your free consultation rather than assuming contingency applies.

What to bring to your consultation

• Every denial, grievance, and appeal letter, with dates
• Your Evidence of Coverage or policy, including any arbitration or suit-limitation clause
• Any letter of medical necessity from your treating physician
• Bills, receipts, and records of what you've paid out of pocket
• Notes from phone calls with the plan, including names and dates
• Any employer plan documents, if your coverage comes through work

Who you'll be working with

Gianelli & Morris holds an AV Preeminent® rating and has represented California policyholders since 1979. Robert S. Gianelli is a Consumer Attorneys of California Street Fighter of the Year honoree and has twice been a Consumer Attorney of the Year finalist. You can read his background on his attorney profile. If you'd like a step-by-step version of the appeal itself, see our guide to the steps to appeal a denied health insurance claim, or return to our main Los Angeles health insurance denial lawyer page.

The information on this page is for general informational purposes and does not constitute legal advice. Every case is unique, and past results do not guarantee future outcomes. Contact a qualified attorney to discuss your specific situation.

Your IMR window and your time to sue may already be running. The IMR application is ordinarily due within six months of your plan's written grievance response, and a policy suit clause can shorten the time to file a lawsuit. Call 213-489-1600 to set up a free, confidential case review with Gianelli & Morris. We represent policyholders throughout Los Angeles County and across California.

Frequently Asked Questions

How much does a health insurance appeal lawyer cost in California?

At Gianelli & Morris, insurance bad faith cases are handled on contingency, so our fees are a percentage of any award we recover. Administrative steps such as a grievance, an Independent Medical Review application, or a Medi-Cal appeal are different. We explain the fee arrangement for those during your free consultation. The IMR itself doesn't cost the enrollee anything under California law.

How long do I have to sue my health insurance company in California?

California courts generally apply a two-year period to bad-faith tort claims (Code Civ. Proc. § 339(1)) and a four-year period to claims on the written policy (§ 337(a)). Both commonly run from the insurer's unequivocal denial. Policies regulated by the Department of Insurance include a suit clause, and accrual rules, tolling, and policy language can shorten or shift these periods. Have an attorney calculate your deadline early.

What is my denied health insurance claim worth?

There's no formula, and no honest lawyer can give you a number before reviewing your file. Value depends on the denied benefit, what you paid out of pocket, any harm the delay caused, whether your plan is governed by ERISA, and whether the insurer's investigation was unreasonable. In a non-ERISA bad-faith case, Brandt fees and, in rare cases, punitive damages may also be part of the picture.

Should I accept the first thing my health plan offers after a denial?

Not before you understand what you'd be giving up. A partial approval or a payment offer may come with a release of other claims, including claims for harm caused by delay. Read any release language carefully and have it reviewed. An approval of care with no release attached is a different situation, and accepting the care usually doesn't waive your other rights.

Does it hurt my claim if my doctor's prior-authorization request was incomplete?

It can complicate the timeline, but it doesn't automatically defeat the claim. Under Health & Safety Code § 1367.01, a plan's decision clock runs from receipt of the information reasonably needed to decide. A missing record usually means resubmitting with a stronger physician letter. Whether the plan asked only for information it actually needed is part of evaluating how it handled the claim.

How long does a health insurance appeal or lawsuit take?

DMHC-regulated plans must resolve a grievance within 30 days, or 72 hours when expedited. After a favorable IMR decision is adopted, the plan has five working days to authorize care or reimburse you. A lawsuit takes longer, and its pace depends on the court's schedule, whether the insurer moves the case to federal court or arbitration, and how much discovery the claim file requires.

Do I need a lawyer for an independent medical review in California?

No. Many people file their own grievance and IMR application, and the DMHC charges nothing. A lawyer becomes more useful when the deadlines are close, when your plan type is unclear, when the delay has already caused harm, or when the denial looks like part of a broader practice. Early advice can also help you avoid statements in an appeal that later complicate a lawsuit.

What if my health insurance comes through my employer?

If a private employer sponsors the plan, ERISA likely governs it, and Gianelli & Morris does not handle ERISA-governed employee benefit cases. You may still have state appeal rights. Insured employer plans, including every Kaiser HMO offered through a private employer, keep DMHC grievance and IMR rights. Government and church plans are exempt from ERISA and generally retain California bad-faith remedies against the insurer.

Will my health insurance case go to trial?

Most civil cases resolve before trial, but you should plan as though yours might not. Some health plan contracts require binding arbitration, which moves the dispute out of court entirely. Our firm has taken health coverage disputes to trial, including the LaRue case against Accountable Health Care, IPA and the Gallimore class action trial against Kaiser.

How do I pay for treatment while my appeal is pending?

That's one of the hardest parts of a denial. Ask your treating doctor's office about payment arrangements, and ask your plan for expedited review if your health is at serious risk. If you pay for care yourself and later win an IMR, the plan must reimburse you within five working days of the adopted decision. Keep every receipt.

If you're weighing whether to pay out of pocket or wait, call 213-489-1600 and we'll talk through how that choice affects your appeal and any later claim.

Can I file a complaint with the state about my health plan?

Yes. Members of HMOs and other Knox-Keene plans can file complaints and IMR applications with the Department of Managed Health Care. Policyholders of CDI-regulated health insurance can request help from the California Department of Insurance. A complaint doesn't replace a lawsuit and doesn't stop the time to sue from running.

Can I sue my health insurer under Insurance Code § 790.03?

No. The California Supreme Court held in Moradi-Shalal v. Fireman's Fund that § 790.03 creates no private right of action, and the Insurance Commissioner enforces it. You can sue for breach of the policy and for breach of the implied covenant of good faith and fair dealing. The unfair practices listed in § 790.03 can still serve as evidence of how a reasonable insurer should have handled your claim.