Consumer Rights

Know Your Rights
Consumers in the United States all have rights when it comes to choosing health insurance.

These rights are often basic such as the right to claim insurance, to have good care, and appeal decisions but there are also many others you should know so you are an informed and intelligent consumer:

  • You have the right to a detailed overview of health service offered by an HMO or insurer.
  • You have the right know if any treatment requires pre-authorization.
  • You have the right to know if you need approval before surgery, chiropractic service, or physical therapy.
  • You have the right know if there are any conditions you have to meet to get a referral to a specialist such as seeing a Primary Care Physician (PCP).
  • You have the right know about different plans so you can make a well-informed decision on treatments and related drugs.
  • You have the right to know about any compensation associated with different plans.
  • You also have the right know the names and salaries of your insurance company’s executive board members.

HMO and Insurer Decision Grievances
HMOs and insurers with a managed care contract are required to have a grievance procedure. A grievance can be filed for any determination other than medical necessity.

You can file grievance in cases such as:

  • Denied referral to specialist
  • No reimbursement for emergency room treatment and care
  • Curtailment of a hospital stay
  • No reimbursement of medically necessary expenses when customer was out-of-network
  • Total denial of coverage or coverage is limited per the contract

You can initiate grievances through a toll-free number; all must be handled within 30 to 40 days, though this depends upon the type of grievances covered. During the grievance process, you have the right to have any medically-necessary claims reviewed by clinical reviewers rather than financial ones thus ensuring your health is put first. You may also appeal a utilization review determination done on an expedited basis if you are undergoing a course of treatment or your health care provider believes an immediate appeal is warranted. Expedited appeals must be decided within two business days.

Expedited appeals maybe accepted in some the following circumstances:

  • Services that are related to the removal of cataract.
  • Procedure that involves the transplant of bone marrow.
  • Surgeries that are related to knee replacement, kidney, heart and liver transplant, rotator cuff surgery and also deviated septum repair.
  • Services such as MRI examination, biopsy, breast reconstruction, mammography.