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CA Department of Insurance

What to Do if You Have a Problem with Your Policy

Contact your health insurer to resolve your problem

  • Talk to your doctor and call your health insurer. Sometimes talking solves the problem.
  • You can file a complaint with your insurer. A complaint is also called a grievance or appeal.
  • Generally, your insurance company must make a decision within 30 days.
  • If your health problem is urgent, your health insurance must do an Expedited Review. It must be done as soon as possible, in 72 hours or less.

If you are not satisfied with your health insurer's review process or decision, call the California Department of Insurance (CDI). You may be able to file a complaint with CDI or another government agency.

If your policy is regulated by CDI, you can file a complaint at any time. CDI reviews cases that involve:

  • Disagreements about the services your health plan must cover.
  • Termination or cancellation/recission of your insurance policy.
  • Exclusions and limitations on services that are usually covered.

Some health insurers also sell plans that are regulated by the Department of Managed Health Care. Your Evidence of Coverage information will tell you if this is the case. Either way, if you contact CDI's help line at 1-800-927-4357 (HELP) and we can help you figure it out.

My claim was denied. Now what?

Your health insurance policy tells you how to appeal if your plan denies your claim or pays less than you think it should.

You have the right:

  • To receive an explanation of your insurer's grievance and appeal procedures.
  • To file a complaint, also called a grievance or appeal, with your insurer.
  • To receive an easy-to-understand written decision on your appeal.
  • To file a complaint with us.

Independent Medical Review (IMR)

In an IMR, independent medical professionals review a medical decision made by your insurance company. You can ask for an IMR if your insurer:

  • Denies, changes, or delays a service or treatment, based on a decision that it is not medically necessary.
  • Will not cover an experimental or investigational treatment for a serious medical condition.
  • Will not pay for emergency or urgent medical services that you have already received.

Visit our IMR pages for more information, or call us at 1-800-927-4357 (HELP).

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