California CDI — Insurance Complaints & Medical Review

The California Department of Insurance (CDI) was created in 1868 as part of a national system of state-based insurance regulation.

Consumer Services and Market Conduct Branch Educates consumers, mediates consumer complaints, and enforces insurance laws through investigation of complaints against insurers and licensees and examinations of insurer claims and underwriting files.

the California Department of Insurance is the consumer protection agency for the nation's largest insurance marketplace and safeguards all of the state’s consumers by fairly regulating the insurance industry.

File a Complaint - Consumers

Consumer & Provider Health Inquiries & Complaints

Independent Medical Review Program (IMR)

E-mail general question or concerns?

If you have an account, you can: Check on the status of your complaint Add new documents to support your complaint File a new complaint Continue as a Guest

We recommend using the electronic complaint forms above. Use of non-electronic complaint forms may delay the process.

In order for us to effectively begin our investigation, please provide any supporting documentation you may have related to this matter along with your Request for Assistance (RFA). □ Supporting documentation (i.e. copies of correspondence between you and the insurance company/broker- agent; declaration page of your insurance policy; canceled checks; letters of claim denial, etc.) □ If you wish to give authority to someone to assist you in filing this Request for Assistance (RFA), please complete the Authorization and Designation of Agent form.

If yes, we will defer the regulatory investigation until the finality of the litigation. We ask that you still complete this form so we have a record of your issue. Once the matter is concluded, we would welcome any information regarding violations of insurance law by the insurer that you or your attorney are willing to provide.

I understand that a copy of this form and all documentation submitted will be provided to the licensee involved in this complaint at any time.

When providing information or documents, please do not include unrequested personal information, such as Social Security Numbers, Driver’s License Numbers, unnecessary health-related information, and credit card or financial information.

If you want to give someone the authority to assist you in the filing of your complaint please fill in Parts A and B below. • If you are a parent or legal guardian filing this complaint for a child under the age of 18, you do not need to complete this form. • If you are filing a complaint for a consumer who cannot complete this form and you have legal authority to act for this consumer, please complete Part B only. Also send a copy of the power of attorney for health care decisions or other legal document that says you can make decisions for the consumer.

claim disputes pertaining to health insurers regulated by the California Department of Insurance.

In order for us to effectively begin our investigation, please provide any supporting documentation you may have related to this matter along with your Health Request for Assistance (HRFA).  Copy of insured’s insurance identification card – both sides  Copies of correspondence between you and the insurance company/agent, including all related Explanation of Benefits (EOBs)  If you wish to give authority to someone to assist you in filing this Health Request for Assistance (HRFA), please complete the Authorization and Designation of Agent form. Please note, this form is required if filing on behalf of an adult child.

The following information is used for statistics only in order to ensure all insureds have access to health insurance. Providing this information is optional and will not affect the complaint process in any way.

File a Complaint - Consumers File a Complaint - Healthcare Providers

An IMR can be requested only if the insurance company's decision involves: The medical necessity of a treatment, An experimental or investigational therapy for certain medical conditions, or A claims denial for emergency or urgent medical services.

Health claims that have been denied by the insurance company because the service or treatment is not covered under the insurance contract. Denials due to coverage issues or other related underwriting policy issues do not qualify for the IMR program. Legal interpretations of policy language, provisions, and terms do not qualify for the IMR program. Bad faith allegations and other demands for extra payments under the health insurance contract do not qualify for the IMR program.

If your request does not qualify for the IMR program, then your claims review request will be referred to the complaint/mediation program within the CDI.

It is necessary in most situations to go through the appeals/grievance process with your health insurance company before applying for an IMR with the CDI. If the insurance company upholds its decision or has not provided a ruling within 30 days of filing the appeal/grievance, then you can file an IMR request.

Please provide any supporting documentation you may have related to this matter.  Copy of insured’s insurance identification card – both sides  Copies of correspondence between you and the insurance company including all related Explanation of Benefits (EOBs)

I hereby request Independent Medical Review of my dispute with the insurer. I authorize the release of any and all of my medical records and information, of any type, of or pertaining to the scope of this authorization including medical, mental health, substance abuse, HIV records, diagnostic imaging reports, and any other type of non-documentary records, as well as pertinent non-medical records and information. This authorizes release by and among all medical providers, the insurer, the California Department of Insurance and any Independent Medical Review Organization. Release and disclosure are authorized only to the extent any of those persons or entities may deem appropriate for a purpose consistent with the review of a complaint regarding health care services. This authorization will expire one year from the date below, except as regarding the Department’s internal use or as otherwise allowed by law. The expiration will apply to all information not previously released pursuant to this authorization. This authorization may be revoked or withdrawn at any time. A revocation or withdrawal will apply to all information not previously release pursuant to this authorization. I attest that the information provided is accurate and truthful.

If you want to give another person the authority to assist you with your Independent Medical Review (IMR), complete Parts A and B below.

You will not be required to pay any kind of application or processing fee for an IMR. The cost of the IMR is paid completely by your insurance company after it has been decided that your request qualifies for an IMR by the CDI.

When the CDI reviews your request for an IMR, the Department may waive the requirement that you first go through your insurance company's appeals/grievance process when an extraordinary or compelling case exists. The Insurance Commissioner may make exceptions based on the criteria listed in CIC Section 10169.3(c) above and based on the Insurance Commissioner finding that you have acted reasonably in the dispute with your insurance company.

The Sixth Step - Implementation. Upon receiving the IMR determination, the Insurance Commissioner adopts the recommendation from the IMR organization immediately. A written decision will be issued by the CDI to you and to your insurance company explaining that the recommendation is binding on the insurance company.

Submitting, being approved for, or participating in an IMR does not prevent you from seeking other legal resolution to your dispute. However, if you decide not to participate in an IMR, you may waive any right you have to pursue legal action against your insurance company in the future regarding the contested health care service. You may wish to seek the advice of an attorney in this matter.

(To Be Completed By Treating Physician) I hereby certify that I am the treating physician for ___________________________ (insured’s name) and that I have requested the authorization for a drug, device, procedure or therapy denied for coverage due to the insurance company’s determination that the proposed therapy is Experimental and/or Investigational. I understand that in order for the Insured to obtain the right to an Independent Medical Review of this denial, as treating physician I must certify that the Insured’s medical condition meets certain requirements. In my medical opinion as the Insured’s treating physician, I hereby certify to the following: (Please check all that apply) (NOTE: Requirements #1 - #3 below must all apply for the member to qualify for an Independent Medical Review).

Consumer Hotline 800-927-4357 (HELP) 800-482-4833 (TTY)

Consumer Hotline 800-927-4357 (HELP) 800-482-4833 (TTY)

CONSUMER SERVICES DIVISION 300 SOUTH SPRING STREET, SOUTH TOWER LOS ANGELES, CA 90013

REQUEST FOR ASSISTANCE (RFA)

HEALTH REQUEST FOR ASSISTANCE (HRFA)

APPLICATION FOR INDEPENDENT MEDICAL REVIEW

PHYSICIAN CERTIFICATION EXPERIMENTAL/INVESTIGATIONAL DENIALS

Report Fraud

Dealing with Catastrophes

The organization shall complete its review and make its determination in writing, and in layperson’s terms to the maximum extent practicable, within 30 days of the receipt of the application for review and supporting documentation, or within less time as prescribed by the commissioner.

If the disputed health care service has not been provided and the insured’s provider or the department certifies in writing that an imminent and serious threat to the health of the insured may exist, including, but not limited to, serious pain, the potential loss of life, limb, or major bodily function, or the immediate and serious deterioration of the health of the insured, the analyses and determinations of the reviewers shall be expedited and rendered within three days of the receipt of the information.

Subject to the approval of the department, the deadlines for analyses and determinations involving both regular and expedited reviews may be extended by the commissioner for up to three days in extraordinary circumstances or for good cause.

(j) An insured may apply to the department for an independent medical review when all of the following conditions are met: (1) (A) The insured’s provider has recommended a health care service as medically necessary, or (B) The insured has received urgent care or emergency services that a provider determined was medically necessary, or (C) The insured, in the absence of a provider recommendation under subparagraph (A) or the receipt of urgent care or emergency services by a provider under subparagraph (B), has been seen by a contracting provider for the diagnosis or treatment of the medical condition for which the insured seeks independent review. The insurer shall expedite access to a contracting provider upon request of an insured. The contracting provider need not recommend the disputed health care service as a condition for the insured to be eligible for an independent review. For purposes of this article, the insured’s provider may be a noncontracting provider. However, the insurer shall have no liability for payment of services provided by a noncontracting provider, except as provided pursuant to Section 10169.3. (2) The disputed health care service has been denied, modified, or delayed by the insurer, or by one of its contracting providers, based in whole or in part on a decision that the health care service is not medically necessary. (3) The insured has filed a grievance with the insurer or its contracting provider, and the disputed decision is upheld or the grievance remains unresolved after 30 days. The insured shall not be required to participate in the insurer’s grievance process for more than 30 days. In the case of a grievance that requires expedited review, the insured shall not be required to participate in the insurer’s grievance process for more than three days. (k) An insured may apply to the department for an independent medical review of a decision to deny, modify, or delay health care services, based in whole or in part on a finding that the disputed health care services are not medically necessary, within six months of any of the qualifying periods or events under subdivision (j). The commissioner may extend the application deadline beyond six months if the circumstances of a case warrant the extension.

If the insured’s physician determines that the proposed therapy would be significantly less effective if not promptly initiated, the analyses and recommendations of the experts on the panel shall be rendered within seven days of the request for expedited review. At the request of the expert, the deadline shall be extended by up to three days for a delay in providing the documents required. The timeframes specified in this paragraph shall be in addition to any otherwise applicable timeframes contained in subdivision (c) of Section 10169.3.

(a) Every disability insurer that covers hospital, medical, or surgical benefits shall provide an external, independent review process to examine the insurer’s coverage decisions regarding experimental or investigational therapies for individual insureds who meet all of the following criteria: (1) (A) The insured has a life-threatening or seriously debilitating condition. (B) For purposes of this section, “life-threatening” means either or both of the following: (i) Diseases or conditions where the likelihood of death is high unless the course of the disease is interrupted. (ii) Diseases or conditions with potentially fatal outcomes, where the end point of clinical intervention is survival. (C) For purposes of this section, “seriously debilitating” means diseases or conditions that cause major irreversible morbidity. (2) The insured’s physician certifies that the insured has a condition, as defined in paragraph (1), for which standard therapies have not been effective in improving the condition of the insured, for which standard therapies would not be medically appropriate for the insured, or for which there is no more beneficial standard therapy covered by the insurer than the therapy proposed pursuant to paragraph (3). (3) Either (A) the insured’s contracting physician has recommended a drug, device, procedure, or other therapy that the physician certifies in writing is likely to be more beneficial to the insured than any available standard therapies, or (B) the insured, or the insured’s physician who is a licensed, board-certified or board-eligible physician qualified to practice in the area of practice appropriate to treat the insured’s condition, has requested a therapy that, based on two documents from the medical and scientific evidence, as defined in subdivision (d), is likely to be more beneficial for the insured than any available standard therapy. The physician certification pursuant to this subdivision shall include a statement of the evidence relied upon by the physician in certifying his or her recommendation. Nothing in this subdivision shall be construed to require the insurer to pay for the services of a noncontracting physician, provided pursuant to this subdivision, that are not otherwise covered pursuant to the contract. (4) The insured has been denied coverage by the insurer for a drug, device, procedure, or other therapy recommended or requested pursuant to paragraph (3), unless coverage for the specific therapy has been excluded by the insurer’s contract. (5) The specific drug, device, procedure, or other therapy recommended pursuant to paragraph (3) would be a covered service except for the insurer’s determination that the therapy is experimental or under investigation.

Moreover, your insurance company must deliver the necessary information and documents to the IMR organization within 24 hours of approval from the CDI of your IMR request.

Please select the link above and use either a license number or name to retrieve the license status and discipline history of an agent, broker, adjuster, bail agent, business entity or another licensee. From there, you can select the available links on the license record to review additional license details.

License Status Inquiry