From the Office of the Insurance Commissioner
It’s not uncommon for a health insurance company to refuse to pay for medical treatment. If it happens to you, it doesn’t have to be the final word.
You can appeal to your insurer. If the answer’s still no, you can appeal to an independent review organization. In addition to appealing a denial, you can also file a complaint with us.
If you want to file an appeal with your health plan, contact them and ask: “What do I need to do to file an appeal?” After that, you’ll need to collect materials that support your appeal, such as documentation from your medical provider and information about your medical condition.
After you send your appeal materials to the health plan, be persistent. Most people don’t win at the first level of appeal, but the odds of winning increase as you reach higher levels of appeals. The chance of winning is highest when your health plan appeal reaches the final level, called an Independent Review Organization.