How to file a complaint with your state insurance department

A complaint to your state insurance department asks the state to check whether your insurer broke a rule. It can help if your plan is bought from an insurance company. It does not help if your employer pays claims itself, and it does not stop the deadline for your appeal. File your appeal or your external review request first, or on the same day, and then complain.

What this means

A complaint is a report to a regulator that a plan or insurer did something wrong, such as ignoring a deadline, giving unclear reasons or refusing to follow its own policy. An appeal is a request to change a decision. They are different. The regulator can look at how the plan behaved. It does not have to decide whether your treatment is covered, and a complaint does not give you the time protections an appeal does.

The state insurance department regulates insurance companies and the policies they sell. Under the federal Public Health Service Act, states enforce the health insurance requirements against insurers, and the federal Department of Health and Human Services steps in only if a state fails to enforce them substantially. Complaints about an insurance company or an insured policy go to the state insurance department. HealthCare.gov also directs consumers to their state Consumer Assistance Program, which can file an appeal for them.

Some states combine roles. In many, external review runs through the insurance department or a sister agency, so the office you complain to may also take your review request. Other states route external review through the insurer. For your state, see the page for your state under all states.

Most state insurance departments say what they will do and what they will not. They can answer questions, look into delays or unfair denials and take enforcement action. They cannot set prices or act as your lawyer. The process on the National Association of Insurance Commissioners’ site is that the complaint is forwarded to the insurer, the insurer must respond, and the regulator decides whether it broke a rule. The same page says an insurer cannot retaliate.

What to do

1. Work out who regulates your plan. Check your insurance card, your denial letter and your plan documents. A job-based plan paid by the employer itself (self-funded) is outside state insurance law. See who regulates your plan and self-funded or fully insured. If you cannot tell, ask your plan in writing, or call the state insurance department and ask whether it has authority.
2. Protect your appeal first. Check the date on your notice, which controls. A complaint does not pause the 180 days for your internal appeal or the four months for external review.
3. Collect your papers. The denial letter, the explanation of benefits, your appeal and the plan’s reply, the dates of any calls and the claim number. Keep it to what happened and when.
4. Say what the plan did wrong, in plain facts. Examples: it did not decide within the time limit, it refused to give you the claim file, the denial letter did not give a specific reason, or it did not tell you how to ask for external review. The regulator complaint builder and the complaint letter help you put it in order.
5. Say what you want. For example: “Please require the plan to decide my appeal and send me the decision in writing.”
6. File through the department’s own complaint page or by phone. Your state page lists the agency and its complaint link where we have them. Use the script for calling the regulator if you phone. Ask for a complaint number.
7. Keep going with your appeal. Note the regulator’s reply time and your own deadlines.

What the department may say, and what to say back

“We do not regulate your plan.” Ask which agency does. A private employer plan is the Department of Labor. A federal employee plan is the Office of Personnel Management. A self-funded state or local government plan is the Centers for Medicare & Medicaid Services. Ask for the number.

“This is a coverage dispute. File an appeal.” Ask whether the plan followed the process rules, such as timing and notice. Say the appeal is filed, and give its date.

“We cannot decide the medical question.” Ask whether an independent external review is available and where to send it. See how to request external review.

The rule

The state insurance department is the primary regulator of insurance companies and their policies, including individual and marketplace plans that are not grandfathered. HealthCare.gov directs consumers with a denial to their state insurance department and to their state Consumer Assistance Program. Self-funded employer plans are outside state insurance law because the federal law on employee benefit plans overrides state laws that relate to those plans but saves state laws that regulate insurance. See HealthCare.gov, internal appeals and title 29, section 1144 of the United States Code.

Watch for

• A complaint is not an appeal. Unless the office tells you in writing that it has filed an appeal for you, assume it has not. Keep your own record of filing dates.
• Self-funded plans. Complaints go to the Department of Labor. See how to get help from the Department of Labor.
• Surprise bills. A complaint that a plan or insurer is not following the No Surprises Act can go to the federal government, which must acknowledge it within 60 business days. See surprise bills.
• Medicare and Medicaid. Different agencies handle these. Start at Medicare or Medicaid and children’s coverage.
• Slow replies. A complaint can take weeks. If you are in a fast-moving situation, use an expedited appeal as well.

What next

• How to get help from the Department of Labor: the right agency for a private employer plan.
• How to request external review: the decision that can bind the plan.
• Free and low-cost help: people who can help with the paperwork.