Jefferson City, Mo.  -  The Missouri Department of Insurance is reminding consumers of their legal right to appeal a health insurance company’s decision to deny coverage for treatment. The appeal process provides consumers and their health care providers the opportunity to offer additional information and resolve any miscommunication relating to their treatment plan.

In Missouri, treatment coverage denials can be appealed if an insurance company decides that a policyholder’s treatment is not medically necessary, is experimental, is not as effective as other treatment options or that a different level of care is required. A consumer can request an expedited appeal in the event of an urgent medical situation.

Consumers who are part of a group health plan have two chances to appeal the decision directly to their insurance company. Individual health plans may provide either one or two levels of appeal, and consumers should refer to their insurance policies for additional information. The department’s Division of Consumer Affairs can provide assistance to policyholders who are working with their insurance company in the appeal process.

Missouri law also provides for an external review process for consumers who receive an adverse decision from their insurance company, or who have not been able to come to an agreement with their insurance company. This review is performed by an Independent Review Organization retained by the department and ensures that consumers receive a fair and impartial appraisal of an insurance company’s denial. The department suggests that consumers utilize all levels of appeal with the insurance company prior to pursuing an external review; however, doing so is not a requirement.

“All Missourians should be aware of their right to appeal the adverse decision of a health insurer,” said John M. Huff, director of the Missouri Department of Insurance. “Insurers are required to include information about your right to appeal and how you can initiate the appeal process in your health plan. If you need assistance do not hesitate to contact the department.”

The department’s Division of Consumer Affairs assesses all external review requests and will notify both the policyholder and the insurance company if the request is eligible for external review. If so, it will be forwarded to the Independent Review Organization, which will then assign the case to physicians who practice and are certified in the specialty involved with the case. The Independent Review Organization will also ensure that the physicians assigned to the file have no personal or professional conflicts with the insurance company.  

Over 30 percent of the cases the Division of Consumer Affairs referred for external review in 2015 were overturned, resulting in nearly $197,000 in consumer recoveries.

In 2016, the number of cases referred to external review is up more than 65 percent as compared to 2015. Of the 62 cases referred for external review to date in 2016, 15 were overturned, resulting in nearly $108,000 in recoveries so far, with 10 reviews still in process. 

Consumers with questions about appeals or external reviews can call the department's Insurance Consumer Hotline at 800-726-7390 or visit insurance.mo.gov.