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:

  • Request an internal grievance;
  • Request an external grievance review; and
  • File a complaint.

 How do I request an internal grievance?

If your insurer denies your claim, you have the right to an internal appeal, known in Indiana as an “internal grievance.”[1] This means you can ask your insurer to conduct a full and fair review of its decision. To file an internal grievance, 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 all 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.
  • 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 grievance process should take a maximum of 45 days.[2]

In which circumstances can I apply for an external grievance review?

During an external review, an independent third party reviews your insurer’s decision.[3] Your insurer will no longer have the final say over whether to approve a treatment or pay a claim. You can request an external grievance review of your insurer’s decision if your insurer denies your coverage after you filed an internal grievance because it determines that your requested treatment was:

  • Not appropriate;
  • Not medically necessary; or
  • Experimental or investigational.[4]

You may be able to skip the internal grievance process and request an expedited external grievance review in urgent situations.[5] Your situation is urgent if waiting 45 days would seriously jeopardize your life or your ability to regain function.

 How do I request an external grievance review?

You should file your request for an external grievance review with your health insurer within 120 days of the most recent determination letter.[6] Your insurer must provide you with information on how to submit your request.[7] Be sure to carefully read your insurance policy and any documentation you received with your determination letter to ensure that you follow your insurer’s instructions closely.[8]

Once your insurer receives your request, it will submit your materials to an independent review organization. An independent reviewer will conduct an investigation and render a decision.[9]

How long will the external grievance review process take?

The external grievance review process should take no more than 15 days after the external grievance is filed.[10] If you requested an expedited external grievance review, the process should take no longer than 72 hours after your request is received.[11]

How do I file a complaint?

If you are an Indiana resident and you have completed the internal appeal and external review processes but still lack access to treatment, you can file a complaint with the Indiana Department of Insurance (“Department”).

Complaint information

Your complaint should include the following information:

  • The name, address, email address, and telephone number of the person filing the complaint (“applicant”);
  • The name of the insured person;
  • The name and address of insurance company;
  • The state where the insurance plan was purchased;
  • Policy number and claim number;
  • If a group policy, the name and address of the employer; and
  • The details of the complaint.[12]

Supporting documents

You must also submit the following supporting documents with your complaint:[13]

  • A copy of your insurance card;
  • Copies of coverage denials or determination letters from your insurer;
  • Copies of any determinations made by internal and external reviewers;
  • Any materials submitted with prior appeals and complaints;
  • Supporting documentation from your health care practitioner;
  • A copy of your insurance policy; and
  • All responses from your insurer.[14]

How to submit

The complaint may be submitted online here, faxed to (317) 234-2103, or mailed to the following address:

Indiana Department of Insurance
Consumer Services Division
311 W. Washington Street, Suite 300
Indianapolis, IN 46204-2787[15]

What happens after the Department receives my complaint?

The Department will process your complaint within 72 hours.[16] You will receive a confirmation letter that includes your problem report number and the name of the Consumer Consultant handling your case. The Consultant will send a copy of the complaint to your health insurer. Your insurer must respond to the complaint within 20 business days. The Department will then provide you with a decision.[17] If the Department determines that insurer violated a law, regulation, or policy, the Department may take corrective action against the insurer, including fines or a lawsuit.[18]

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

You can contact the Indiana Department of Insurance at (800) 622-4461 or (317) 232-2426. The Department is open from 8:00 a.m. to 4:15 p.m. Monday through Friday.

[1] Ind. Code Ann. § 27-8-28-6 (2016).

[2] Ind. Code Ann. § 27-8-28-17 (2016).

[3] Appealing a Health Plan Decision: External Review,, (last visited Nov. 26, 2016).

[4] Internal Grievance Review Procedures, Indiana, (last visited Nov. 26, 2016).

[5] Appealing a Health Plan Decision: Internal Appeals,, (last visited Nov. 26, 2016).

[6] Ind. Code Ann. § 27-8-29-13 (2016).

[7] Id.

[8] Id.

[9] Id.

[10] Ind. Code Ann. § 27-8-29-15(a)(2) (2016).

[11] Ind. Code Ann. § 27-8-29-15(a)(1) (2016).

[12] Submit a Complaint Online, Indiana Department of Insurance, (last visited Nov. 26, 2016).

[13] File an Insurance Company Complaint, Indiana Department of Insurance, (last visited Nov. 26, 2016).

[14] Complaint to Federal Government Agency: Patient, Legal Action Center, (last visited Oct. 17, 2016).

[15] Insurance Complaint Form, Indiana Department of Insurance, (last visited Nov. 26, 2016).

[16] Complaints, Indiana Department of Insurance, (last visited Nov. 26, 2016).

[17] Insurance Complaint Form, Indiana Department of Insurance, (last visited Nov. 26, 2016).

[18] Complaints, Indiana Department of Insurance, (last visited Nov. 26, 2016).