High-Risk Insurance

What if My Application for High-Risk Insurance is Denied or I Disagree with a Decision?

You may disagree with a decision that your child is not eligible under your state’s high risk insurance pool. Also, if your child is deemed eligible and receives coverage, you may disagree with a specific decision to deny coverage for a service your child used or needs to use.

In such cases, there are usually several ways to appeal the decision. Check with your state’s high risk insurance plan to learn about its specific appeal or grievance procedure.

Although states may differ, usually you will start with what is called an “internal appeal.” It is called an internal appeal because it is decided by people who work at your state’s high risk insurance plan. The first step in an internal appeal is to send a letter or form to your state’s plan administrator. This letter or form must provide details about your appeal, including why you think the decision was wrong. See the section on this Web site called Private Health Care Coverage for suggestions about what to include in this letter or form. You should receive a decision in writing on your first appeal within a specified time frame that depends upon the specific rules in a state program.

If you also disagree with the decision on appeal, the next step is to send a letter or form to an internal committee that is called the Grievance Committee, or a similar name. It, too, must return a decision to you in writing within a certain time frame.

If you are still dissatisfied with the results, your next step is an external appeal. Your appeal will now be decided by people outside of the high risk insurance plan. Ask your high risk insurance plan or your state department of insurance how and where to file an external appeal. You will begin an external appeal by submitting in writing your reasons for disagreeing with a decision made by your high risk insurance plan. You may decide at this point to involve an attorney in your appeal. Your appeal will be reviewed and a decision sent to you in the mail within a specified time period.

Once you have taken every step available in an external review, your remaining option is to file a lawsuit in court. Consult with an attorney to determine whether this is an appropriate choice.