Your Grievance and Appeal Rights
If you have a complaint or question, you may wish to first contact your insurance company. Many complaints can be resolved quickly and require no further action. However, you do not have to file a complaint with your insurance company before you file a complaint with the appropriate state agency.
Medigap insurance companies are required to have an internal grievance procedure to resolve issues involving Wisconsin mandated benefits. If you are not satisfied with the service you receive, your insurance company must provide you with complete and understandable information about how to use the grievance procedure. You have the right to appear in person before the grievance committee and present additional information.
Insurance companies are required to have a separate expedited grievance procedure for situations where your medical condition might require immediate medical attention. The procedure requires insurance companies to resolve an expedited grievance within 72 hours after receiving the grievance.
Medigap insurance companies are required to file a report with the Office of the Commissioner of Insurance (OCI) listing the number of grievances they had in the previous year.
If you are not satisfied with the denial of a benefit by your Medigap insurance company, you may appeal the decision. The insurance company must offer you the opportunity to submit a written request that the insurance company review the denial of benefits. Your policy or group insurance certificate and Outline of Coverage describe the benefit appeal procedure. If the insurance company denies any benefit under your Medigap policy, the insurance company must, at the time of denial, provide you with a written description of its appeal process.
For Wisconsin mandated benefits under Medicare supplement policies, if you are not satisfied with the outcome of a grievance, and the grievance involves a dispute regarding medical necessity or experimental treatment, you or your authorized representative may request that an independent review organization (IRO) review your insurance company's decision. The independent review process provides you with an opportunity to have medical professionals who have no connection to the insurance company review the dispute. You can choose an IRO from a list of review organizations certified by the OCI. The IRO assigns the dispute to a clinical peer reviewer who is an expert in the treatment of your medical condition. The clinical peer reviewer is generally a board-certified physician or other appropriate medical professional. The IRO has the authority to determine whether the treatment should be covered by the insurance company.
Your insurance company will provide you with information on the availability of this process whenever it makes a determination that is eligible for the independent review process. Information regarding the IRO process is available on OCI's Web site at oci.wi.gov/pub_list/pi-203.htm.