The Grievance Process Required by Law for Insurance Policyholders
In the language of California insurance law, if you have a complaint about the quality of care or service you are getting from your insurance company, that complaint is technically known as a grievance. Once the insurance company receives a complaint that falls within the category of a grievance, several things must happen, and they must occur within statutorily defined timelines. Below we look at the grievance process required by law for health insurance plans in California. If your request or claim for healthcare coverage was unreasonably delayed or denied by your insurance company, contact Gianelli & Morris to speak with an experienced California bad faith insurance lawyer.
California Health Insurance Law
Health insurance in California is governed by the Knox-Keene Health Care Service Plan Act of 1975, which can be found in sections 1340 through 1399.874 of the California Health and Safety Code. Knox-Keene occupies over 600 pages of laws, and the regulations implementing the law go on for nearly another 400 pages. The provisions of the law regarding grievance policies start at section 1368 and continue through section 1368.03. Highlights of the key points of the law are provided below.
The Basic Grievance Process
Section 1368 outlines the basic requirements for health care service plans to establish and maintain a grievance system. This system must provide a mechanism for policyholders to submit complaints and seek resolutions for issues such as claim denials, service delays, or inadequate care. The grievance system must be approved by the Department of Managed Health Care and provide reasonable procedures that ensure adequate consideration of grievances and rectification when appropriate.
Key elements of the grievance process include written acknowledgment and a resolution timeline. Firstly, the plan must acknowledge the receipt of a grievance in writing within five calendar days. Next, the grievance must be resolved within 30 days, with a possible extension to 45 days if additional time is necessary. The insurer must submit its decision in writing and include the rationale it used for making the decision.
Once a complaint is received, the insurance company has five days to send a written acknowledgment to the policyholder acknowledging the company has received the complaint. They must also include the name and phone number of a company representative who will serve as a contact person should the policyholder need to get in touch or have any questions.
Once the insurer has made a decision, the company must provide a written response with a clear and concise explanation of the reasons behind its response. If the issue involves a delay, modification or denial of a claim, the insurer must describe the criteria used and the clinical reasons for its decision. The response should also specify the applicable policy provision in appropriate situations, such as when the insurance company claims coverage is excluded under the policy.
If the complaint involves policy cancellation, rescission, or nonrenewal, the company must continue to provide coverage until a final determination has been made, except in cases where the policy has been canceled due to nonpayment of premiums.
Expedited Grievances
Section 1368.01 addresses expedited grievances, which apply to situations where the standard resolution timeline could seriously jeopardize the enrollee’s life, health, or ability to regain maximum function. Key provisions include urgent resolution and immediate notification. Expedited grievances must be resolved within 72 hours, and the health plan must immediately inform the enrollee of the resolution.
Assistance for Enrollees
Under Section 1368.015, health plans are required to provide assistance to enrollees who have limited English proficiency or other communication barriers. This ensures all policyholders have equal access to the grievance process. According to this section of the law, health plans must offer language assistance services at no cost. In addition, grievance-related documents must be available in multiple languages and accessible formats. Policyholders must be given this information upon enrollment and annually, including the location and phone number where grievances may be submitted. The health plan should also provide forms for enrollees to use.
Information on the Grievance Process
Section 1368.016 mandates that health plans provide clear and concise information about the grievance process to enrollees. This includes an explanation of rights and a step-by-step guide on how to file a complaint. Enrollees must be informed of their rights to file a grievance, and the health plan must provide detailed instructions on how to submit a grievance and what to expect during the process.
Independent Medical Review
Section 1368.02 introduces the option for an Independent Medical Review (IMR) for enrollees who are dissatisfied with the outcome of their grievance. Under the law, an IMR can be requested if the grievance involves a denial of service based on medical necessity, experimental treatment, or a disputed health care service. Once requested, the IMR process must be completed within 30 days, or within three days for urgent cases.
Department Oversight
Section 1368.03 grants the Department of Managed Health Care (DMHC) oversight authority to ensure health plans comply with the grievance process requirements. This includes monitoring compliance as well as enforcement actions. The DMHC monitors health plans’ adherence to grievance process regulations and can take enforcement actions against non-compliant health plans, including fines and penalties. In previous blog posts, we have noted numerous instances where Anthem and other health plans were fined tens of thousands of dollars for failure to establish and maintain a grievance system for policyholders as required by law. This continues to happen time and time again despite the law having been in place for many years.
Contact Gianelli & Morris for Help With Bad Faith Health Insurance Claim Denials in California
At Gianelli & Morris, we are dedicated to representing policyholders and ensuring they receive fair treatment in their insurance claims. If you believe your claim was handled in bad faith, contact us today for legal support. Call 213-489-1600 for a free consultation to evaluate your case.
