What Does California Law Require from a Health Insurance Grievance System?

In a recent post, we reported on a Department of Managed Health Care (DMHC) survey of the quality of care offered by Anthem Blue Cross to its California policyholders. The survey found 14 serious shortcomings, ten of which were shortcomings in the manner in which Anthem operated its customer grievance system. The DMHC’s report wasn’t just pointing out ways that the grievance system might be improved; it was explaining the ways that Anthem’s plan violated California laws governing health care providers. Learn more below about the legal requirements for health care grievance systems in California, and speak with a Los Angeles health care claim denial lawyer if your health insurance company is not playing fair.

What is a grievance system, and why does it matter to health insurance customers?

“Grievance system” is the term used by California’s Health and Safety Code to describe how policyholders can submit complaints to the insurer about the quality of the care or service they’ve received. Filing a grievance is typically the first step that a health insurance customer takes in changing or improving the quality of care they receive. California legislators have created laws protecting the ability of policyholders to file a complaint so that these customers can feel confident that their health care needs are being heard and taken seriously. When health insurance companies fail to consider or respond to customer complaints, a policyholder’s physical health may end up being jeopardized.

What does California’s Health and Safety Code require of grievance systems?

California has enacted numerous regulations governing health care grievance systems, most of which focus on publicizing how to file grievances and how plans must respond to them. Health plans are required by law to have a grievance process in place to resolve enrollee complaints within 30 days. The law requires that policyholders must be clearly informed of how to file a grievance and that assistance is available to file grievances. Health care plans are legally required to acknowledge receipt of the grievance within five days after receiving the grievance, and this notice must include the name of the person who can be contacted to follow up on the grievance and the company’s response.

Once the insurer has reached a conclusion on the grievance, it must submit its decision and the reasons it reached that decision to the policyholder in writing. If grievances are based on emergencies, then the insurer must address those grievances by the close of business on the following day. The health care provider must also notify policyholders that they are entitled to interpretation in several languages. Anthem failed to uphold its responsibilities under several of these duties, forcing policyholders to either go without care or seek legal help to get the coverage they paid for and were entitled to receive as customers.

If you have been denied benefits under your California health insurance policy, get aggressive and experienced legal help obtaining the coverage and potential damages you’re owed by contacting the Los Angeles offices of Gianelli & Morris for a free consultation on your case at 213-489-1600.