How to File a Health Insurance Complaint (50-State Guide)

Are you having problems or complaints about your health or medical insurance? Is your health insurance refusing to pay your claim? Health insurance companies are bound by state and federal laws. If they violate these laws or fail to honor their policy obligations, you may be able to file a complaint with the government agency that regulates them and pursue legal action in small claims court. 

It's important to follow key steps to ensure you have a well-documented and strong case and understand the process clearly. This article will help guide you on the steps you may take to get the justice you deserve from a health insurance company.

Your health insurance policy is a contract between you and your health insurance company. Your policy can normally be found on your online account, or you can likely request a copy by phone. 

Once you have access to your health insurance policy: 

• Understand your coverage: read through your policy carefully, paying attention to the specific terms, conditions, and exclusions. This will help you determine whether the insurance company's decision violates your policy.

• Know the appeals process: many policies have specific procedures for resolving disputes between you and the health insurance company or appealing a claim denial directly with them.

Before escalating your complaint, you should try to resolve your complaint directly with the health insurance company. 

• Contact customer service: Start by contacting the insurance company’s customer service or claims department to try to resolve the issue directly. It's possible that there was a misunderstanding or clerical error.  This could be via phone, email, or an online portal.

• Ask for an explanation in writing: If your claim was denied, request a detailed explanation of the reasons behind the denial.

• Escalate to a Supervisor: If unresolved, ask to speak to a supervisor to see if they can help get your claim resolved.

Keep a paper trail and document everything: 

• Keep detailed records: Record all interactions with the insurance company, including phone calls, texts, emails, letters, and any other communication. Write down dates, times, representatives' names, and summaries of conversations.

• Organize your paperwork: Have all your medical bills, denied claims, and policy documents in one place.

This way, if you later need to escalate to submitting a government complaint or suing in small claims court, you have your evidence ready. 

If communicating via phone or email with the health insurance company doesn’t work, consider sending a demand letter. A demand letter is a formal letter that explains what happened and requests that they resolve the problem. 

Here are some reasons why you should consider sending a demand letter to your health insurance company:

1. A demand letter signals to the health insurance company that you are serious about the issue and willing to take action to resolve it. Many problems are resolved by simply sending a demand letter.

2. If you end up filing a small claims lawsuit later on, the judge in your case may ask if you tried to resolve the problem out of court. By sending a written demand letter, there is a record of your attempt to resolve the problem out of court that you can include in your evidence. 

3. A demand letter will also help you organize your facts and evidence and create a timeline of events. This will help you remain consistent and factual as you go through the steps to resolve your complaint. 

The BBB is a non-profit that serves as an intermediary between health insurance companies and consumers. It’s not a government agency and cannot force the health insurance company to resolve a disagreement with you. However, most health insurance companies do care about BBB reviews and complaints.  

BBB reviews give other consumers confidence when choosing a health insurance plan, and health insurance companies don’t want negative BBB complaints.

Filing a complaint with the BBB lets others see if a health insurance company has had issues before, and this helps people (business owners or individuals) decide whether to use their insurance plans or not.

Many users, however, complain about the BBB's inaction when reviewing complaints.  The BBB has no legal power, so its only influence comes from the threat of lowering the business's rating. If the business doesn't care about its BBB rating, then nothing will happen. Review our guide about when it’s worth filing a BBB complaint. 

Reasons why some companies respond to BBB complaints 

• If the health insurance company is accredited with the BBB and doesn't respond to a BBB complaint, its accreditation may be revoked, and the complaint becomes part of its BBB profile.

• If the health insurance company is not accredited with the BBB, the complaint will become part of their BBB profile.

How to file a complaint with the Better Business Bureau (BBB):

1. Go to the Better Business Bureau website. You will need to confirm whether the health insurance company has a BBB profile. 

2. Scroll to the bottom of the page and click the button “File a Complaint” 

What to Expect Once you Submit your Complaint to the BBB:

• The BBB will forward your complaint to the health insurance company within 2 business days.

• The company will be asked to respond within 14 days, and if a response is not received, a second request will be made.

• You will be notified of the company’s response when the BBB receives it (or notified that they received no response).

• Complaints against health insurance companies are usually closed within 30 business days.

Most health insurance companies have processes for customers to appeal a claim denial. It is important to research how the appeal process works, meet any deadlines, and submit any requested paperwork. Note that you sometimes have to log in to your member page to access information. Sometimes, information is provided after you pass your member login page.

Here is how to file an internal appeal with some of the most popular health insurance companies: 

Each state has a specific government agency that handles complaints against a health insurance company. When filing a complaint, make sure to include your policy number, detailed descriptions of the issue, and any relevant documents (e.g., denial letters, bills, communications).

Below you will find where to file a complaint against a health insurance company in your state: 

If you work for a state regulatory agency and need to update the link in the table above or provide consumers with additional information, please contact us at [email protected]. 

What happens after you file a complaint? 

• Each state’s process for handling a complaint against a health insurance company varies. 

• Most state regulatory agencies don’t have the authority to force the health insurance company to resolve your dispute and may refer you to small claims court. 

• Some states will send a copy of your complaint to the health insurance company, which may lead the company to feel pressured to resolve it.

If your complaint is about a violation of the Affordable Care Act (ACA), you can also file through healthcare.gov 

If the financial damage is significant and the health insurance company nor the state insurance commission resolves the issue, consider taking the health insurance company to small claims court. Depending on the case, you may want to consult an attorney to discuss your options, especially if the issue is serious and/or involves a lot of money.

Remember, just because a health insurance company did not pay for your claim, it does not mean that they acted illegally. It is up to a judge to decide whether the health insurance company should reimburse you for your claim.

Don’t Delay in Suing

There are time limits for filing lawsuits, known as statutes of limitations, which vary by state and the type of claim (e.g., breach of contract vs. bad faith). It’s crucial to act promptly if you believe you have grounds for a lawsuit.  

Before You File a Lawsuit

As you prepare your case, it is of utmost importance that you show the judge that you acted in good faith and that you tried to resolve the issue out of court.   

That is why it is so important to be able to show in your lawsuit that you: 

1) contacted the health insurance company directly, 

2) sent them a demand letter, and 

3) filed a complaint with the state government agency regulating health insurance.

This shows the judge that you took every possible action to solve the problem before filing a lawsuit. 

Tips to Prepare for Small Claims Court

• Check if there have been similar lawsuits against your health insurance company to demonstrate a pattern. 

• Check if there have been similar complaints against your health insurance company on review platforms like the BBB. 

• Review our guide on how to prepare for small claims court. 

Under What Circumstances Can You File a Lawsuit Against a Health Insurance Company

You can file a lawsuit against a health insurance company under certain circumstances, particularly when the company has violated its contractual obligations or legal requirements. 

Here are the key situations where a lawsuit may be appropriate:

Denied Claims Without Justification

If your health insurance company refuses to pay a claim that should be covered under your policy without a valid reason, you may have grounds to sue for “breach of contract”. This can happen if:

• The procedure is listed as covered, and all policy requirements were met.

• The insurer does not provide a clear or valid reason for the denial.

Bad Faith Insurance Practices

"Bad faith" occurs when an insurance company doesn't handle your claim fairly or follows dishonest practices. Examples include:

• Unreasonable delays in processing or paying claims.

• Misrepresenting the terms of your policy.

• Failing to investigate a claim properly.

• In such cases, you may be able to sue for “bad faith insurance” practices, which may allow for compensation beyond the denied claim.

Violation of State or Federal Laws

Insurance companies must follow state and federal laws. If your health insurance provider violates these regulations (such as unfair claims handling practices), you may be able to file a lawsuit. This could involve violations of:

• State insurance regulations (each state has its own rules about fair insurance practices).

• Federal laws, such as the Affordable Care Act, if applicable.

Failure to Honor Policy Terms

If the health insurance company fails to meet the terms of the policy, such as not covering services that are explicitly listed, you may be able to sue for “breach of contract”. This would typically involve:

• The insurer refuses to cover certain treatments or procedures that are clearly stated as part of your coverage.

• Misinterpreting or ignoring clauses in the policy to avoid paying claims.

Unlawful Cancellation of Coverage

If your insurance company cancels your policy unfairly or illegally, you may have grounds for a lawsuit. This could occur if:

• They cancel your policy without proper notice.

• The cancellation violates state insurance laws or the terms of the contract.

Deceptive Marketing or Misrepresentation

If the insurance company misled you when you signed up for the plan or misrepresented the coverage, you may be able to sue for “fraud or misrepresentation”. 

This can happen if:

• The insurer claimed certain procedures were covered but later denied those claims.

• Important details were hidden or unclear in the policy.

Negligence

If the insurance company’s negligence causes you harm (e.g., financial loss due to improper claim handling), you might sue them for “negligence”. This would be based on their failure to fulfill the duties outlined in your policy.

Continue Reading: Guide on How to Sue in Small Claims Court.