Filing an appeal or complaint

How to file a complaint

It is the job of the Georgia Department of Insurance (DOI) to protect insured Georgians by working with people like you and insurance companies. You can file a complaint with the Department of Insurance (DOI) if you think your insurer is doing something wrong. You may also file a complaint if:

• You are having a problem with your premiums (ex: your premium goes up by a lot very quickly)

• You cannot find a doctor that accepts your insurance

• You think your coverage has been cancelled without reason

If you want to file a complaint, go to oci.ga.gov/ConsumerService/complaintprocess. aspx.

After you fill out the online form, here’s what will happen:

1. DOI will send a copy of your complaint to the insurance company. DOI will ask for the company to respond to the complaint. The company will have to provide documents and details about your complaint.

2. DOI will look at the documents that the insurance company gives them, and then decide if the insurer acted correctly.

3. DOI will also figure out if the insurance company broke any laws. If so, they will make sure the insurance company fixes the problem.

How to file an appeal

Sometimes, your health insurance company will say "no" to a claim or only pay for part of it. If that is the case, you have the right to appeal. There are two kinds of appeals—internal appeal and external review.

Filing an Internal Appeal

If your insurance company will not pay your claim or cancels your insurance coverage, you can file an internal appeal. First, ask your insurance company how to file an internal appeal. Follow the instructions that your insurer gives you. Or you can write a letter to the company. If you write a letter, include your name, claim number, and health insurance ID number. With your forms or letter, include any extra information you want the insurance company to know, like a letter from your doctor.

  • If your insurer changes its mind and pays the claim, then you don’t have to do anything more. Your appeal was successful!
  • If your insurance company still says “no” to your claim, you can ask for an external review. If you have an urgent health need, you can ask for an external review at the same time as your internal appeal.

An external review means that the Georgia Department of Insurance (DOI) looks at your claim and decides if the insurance company should pay for it.

You have to ask for a review within 60 days of getting the results of your internal appeal. (Some insurance companies allow you to have more time. Your internal appeal notice should tell you this information.)

To ask for an external review, go to: www.oci.ga.gov/consumerservice/complaintprocess.aspx.

DOI will make a final decision. The decision will either:

  1. Support the health insurance company’s denial. If that is the case, you must pay for the claim;

OR

  1. Support you and make the company pay your claim.

Your insurer is required by law to accept DOI’s decision.

Other helpful tools & resources (5 items) Go to Library

You’re Covered, Now What?

pdf

Common Scams and Concerns: Affordable Health Care

pdf

Health Insurance Complaints and Appeals

pdf

Get Insured. Stay Insured.

pdf

My Health Insurance User’s Manual

pdf