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Complaints Against a Health Carrier
WHAT TO DO IF YOU HAVE A DISPUTE WITH YOUR HEALTH CARRIER:
You may not need a lawyer to resolve most disputes with an insurance agent or a health carrier. Start with contacting your health carrier's customer service office. Most companies have toll-free telephone numbers for quick service. If you do not receive satisfaction, ask about the health carrier's procedures for appealing decisions and/or file a written complaint with the Department of Insurance and Financial Services (DIFS).
HOW TO FILE A COMPLAINT WITH DIFS:
If working directly with the health carrier doesn't satisfy your concerns, you may wish to file a written complaint with DIFS. You can obtain a complaint form and instructions for filing a written complaint from our web site (click here for the health coverage complaint form) or by calling DIFS toll free at 1-877-999-6442. We will send the health carrier a copy of your complaint and ask them to explain its position. Health carriers are required by law to respond to DIFS. We will review all of the facts to make sure the health carrier has followed its contract with you, and that it has also complied with insurance rules and laws.
If your complaint is not against a health carrier, but rather against another type of entity that DIFS regulates (financial institutions, securities, agents, broker-dealers, or insurance companies regarding life, auto, home), click here for information on how to file a complaint.
Health Coverage Grievances and Appeals
INTERNAL GRIEVANCE PROCESS:
Under Michigan laws, each health carrier must establish an internal formal grievance process. This process provides the member or their authorized representative an avenue to seek resolution when there has been an adverse determination. For more information on the internal grievance process, click here.
PATIENT'S RIGHT TO INDEPENDENT REVIEW ACT (PRIRA):
The Patient's Right to Independent Review Act (PRIRA) is a Michigan law that provides patients with appeal rights due to adverse decisions made by health carriers regarding a denial, reduction, or termination of health care services. The PRIRA external review process applies after the patient has exhausted the health carrier's internal grievance process. For more information on PRIRA, click here.