Connecticut

My insurer refuses to cover my prescribed treatment. What can I do?

If your insurer denies your coverage, you can challenge your insurer’s decision by completing the following steps in order:

  • Appeal the decision;
  • Request an external review; and
  • File a complaint.

 How do I request an internal appeal?

If your insurer denies your claim, you have the right to an internal appeal (also referred to as a “grievance”).[1] This means you can ask your insurer to conduct a full and fair review of its decision. To appeal the denial, you should do the following:

  • Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
  • Collect information. In addition to the determination letter, collect the documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
  • Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents.
  • Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
  • Request an urgent care appeal, if applicable. If your request for treatment is urgent, contact your insurer immediately and ask for instructions on how to obtain an urgent care appeal. Your request may be considered urgent if one of the following applies to you:
    • Standard timeframes for processing a standard appeal would seriously jeopardize your life, health, or ability to regain maximum function;
    • Your treating physician feels that you would experience severe pain that could not be adequately managed without the requested services; or
    • You are seeking services related to a substance use disorder or co-occurring mental health disorder.[2]
  • Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
  • Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.

How long should the internal appeals process take?

The internal appeals process should take a maximum of 30 days if you have not yet received the requested service or treatment and a maximum of 60 days if you have received the service or treatment but are waiting for reimbursement.[3] Your insurer must respond to you within 72 hours from receiving your request if you asked for an expedited review.[4]

In which circumstances can I apply for an external review?

During an external review, an independent third party reviews your insurer’s decision.[5] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. You may only obtain an external review if your plan was supposed to cover your treatment, but your insurer denied your claim for one of the following reasons:

  • The requested treatment was not medically necessary;
  • The treatment was experimental or investigational;
  • You are not eligible for the treatment or medication; or
  • Your insurer rescinded your policy.[6]

You can skip the internal appeals process and request an expedited external review if one of the following applies:

  • Your situation is urgent (meaning that waiting 30 to 60 days would seriously jeopardize your life or your ability to regain function);
  • Your treatment physician feels that you would experience severe pain that could not be adequately managed without the requested services; or
  • You are seeking services related to a substance use disorder or co-occurring mental disorder.[7]

How do I request an external review?

You should submit your request for an external review to the Connecticut Department of Insurance (“Department”).

Information

You can find a copy of the external review request form here. Be sure to include the following information in your request:

  • A copy of your medical insurance identification card;
  • A copy of the final denial letter from your insurance company;
  • A letter of support, treatment notes, and test results from your health care provider;
  • Your personal description of the issue;
  • Any current medical literature or studies showing the effectiveness of the treatment you are requesting, if such treatment has been denied as experimental/investigational;
  • Any medical documents not previously submitted to your insurance company; and

Filing fee

You must submit a $25 filing fee by check or money order to Treasurer, State of Connecticut. The fee can be waived for financial hardship based on your income level. If you believe you have a financial hardship, you should complete the Request for Waiver of Filing Fee, which will be included in the external review packet.[8]

Expedited external reviews

If you are requesting an expedited external review, you should also ask your health care provider to complete the Physician Certification Form (click here). You should submit that form with your request.[9] If the services relate to a mental health disorder or substance use disorder, an expedited external review will automatically be granted and the Physician Certification Form is not required to be submitted.[10]

How to submit a standard review

Mail your application materials to:

Connecticut Insurance Department
Attn: External Review
P.O. Box 816
Hartford, CT 06142-0816[11]

How to submit an expedited review

You should mail your request for an expedited review and supplemental documents overnight to:

Connecticut Insurance Department
Attn: External Review
153 Market Street, 7th Floor
Hartford, CT 06103[12]

You must request an external review within 120 days of receiving the last decision letter from your insurer.[13] Be sure to make a copy of all documentation for your own personal records.

How long will the external review process take?

The length of time for an external review process varies based on the services or treatment you requested and whether you requested an expedited external review.

  • External Review
    • Standard treatment: No more than 45 days.
    • Experimental or investigational treatment: No more than 20 days.[14]
  • Expedited External Review
    • Standard treatment: No more than 72 hours;
    • Experimental or investigational treatment: No more than five days;
    • Specific behavioral health services (automatically expedited): No more than 24 hours.[15]

How do I file a complaint?

If you are a Connecticut resident and your insurer denies your coverage after the external review process, you can file a complaint with the Department.

Complaint information

Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (e., complainant);
  • The name of the insured individual, if different from the complainant;
  • The names of any other parties involved (for example, the plan administrator);
  • The name of insurance company and the type of insurance;
  • Claim information, including the policy number, certificate number, and claim number, date of denial, and amount in dispute;
  • The reason for and details of the complaint; and
  • What you consider to be a fair resolution.[16]

Supporting documents

You can submit the following supporting documentation with your complaint:

  • Medical bills;
  • Contracts; and
  • Correspondence between you and your insurer.[17]

How to submit

You can submit your complaint online here. If you submit an online complaint, you should scan the supporting documents and attach them to your complaint.[18] Alternatively, you can print a copy of the complaint found here and mail it along with the supporting documents to:

Connecticut Insurance Department
Attn: Consumer Affairs Division
P.O. Box 816
Hartford, CT 06142-0816[19]

What happens after the Department receives my complaint?

The Department will assign an analyst to review your complaint.[20] You will receive acknowledgment of receipt of the complaint and a copy will be sent to your health insurer for a response.[21] Once the response is received, the analyst will determine how to resolve the complaint.[22] Upon investigation, the Department will either require the insurance company to cover or deny the claim.

Who should I call if I have any questions about filing a complaint?

You can contact the Connecticut Consumer Affairs Division helpline at (860) 297-3900 or (800) 203-3447. The Department is open from 8:00 a.m. to 4:30 p.m., Monday through Friday.


[1] Appealing a Health Care Decision: How to Appeal an Insurance Company Decision, Healthcare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/appeals/ (last visited Nov. 25, 2016).

[2] Insurance Department Appeals & External Review Guide, (Oct. 2013), State of Connecticut, http://www.ct.gov/cid/lib/cid/External_Appeal_Consumer_Guide.pdf.

[3] Conn. Gen. Stat. § 38a-591e (2016).

[4] Id.

[5] Insurance Department Appeals & External Review Guide, (Oct. 2013), State of Connecticut, http://www.ct.gov/cid/lib/cid/External_Appeal_Consumer_Guide.pdf.

[6] Id.

[7] Request for External Review, State of Connecticut Insurance Department, http://www.ct.gov/cid/lib/cid/External_Review_Application.pdf (last visited Nov. 25, 2016).

[8] Id.

[9] Id.

[10] Id.

[11] Id.

[12] Id.

[13] Id.

[14] Conn. Gen. Stat. § 38a-591b (2016).

[15] Insurance Department Appeals & External Review Guide, (Oct. 2013), State of Connecticut, http://www.ct.gov/cid/lib/cid/External_Appeal_Consumer_Guide.pdf.

[16] Consumer Complaint Form, State of Connecticut Insurance Department, http://www.ct.gov/cid/lib/cid/cons.pdf (last visited Nov. 25, 2016).

[17] Id.

[18] Instructions, State of Connecticut Insurance Department, https://cidonline.ct.gov/ccf/ (last visited Nov. 24, 2016).

[19] File a Complaint by Mail, State of Connecticut Insurance Department, http://www.ct.gov/cid/cwp/view.asp?a=1272&Q=479568 (last visited Nov. 24, 2016).

[20] Id.

[21] Id.

[22] Id.