Health Insurance Regulations

Your rights in a dispute with your health insurance company vary depending upon the type of policy and regulations involved. For purposes of this discussion we will deal with commercial policies, not Medicare.

The Arizona Department of Insurance regulates fully-insured policies such as individual and small group plans. Self-insured plans like those offered by many large employers are regulated under the Employment Retirement Security Act (ERISA.) Under a self-insured plan the employer pays the claims, and hires an insurer such as Blue Cross to process claims and provide a network of providers to their employees. Essentially, the employer is the insurance company.

Whether you have a fully insured plan or a self-insured plan, the first step in a dispute is to simply ask the insurance company to reconsider. If they agree to pay the claim you are all done, there is nothing more to do.

If the insurer determines once again that they will not pay the claim, you typically have the option of having your claim reviewed by a third party hired by the insurer specifically for such situations. If the claim is denied once again, it is at this point when it matters if you have a fully insured or self-insured plan.

Those with fully insured plans can petition the Department of Insurance to review the situation, documenting the first two denials of course. The Department of Insurance will investigate the actions taken by the insurer and policyholder.

Those individuals insured through a self-funded plan do not have the option of bringing their grievance to the Department of Insurance, because the state agency does not regulate such plans. Under ERISA rules and regulations the policyholder must deal with the US Department of Labor to file a complaint. It is highly recommended that the employee first attempt to settle the matter through the company’s Human Resources department before dealing with the Department of Labor.

Before filing any appeal, acquaint yourself with your insurance company’s rules and regulations regarding your right to appeal. There will be very specific information on the procedure involved to appeal a claim. Follow the rules, and document everything, including names, dates, and time of all interactions.

Most importantly, the best way to avoid having to file an appeal in the first place is to know your plan before receiving services.