Complaints Against a Health Carrier
What to do if you have a dispute with your health carrier
You do not need a lawyer to resolve most disputes with an insurance agent or a health carrier. Start with contacting your health carrier's customer service office. Most companies have toll-free telephone numbers for quick service. If you do not receive satisfaction, ask about the health carrier's procedures for appealing decisions and/or file a written complaint with the Department of Insurance and Financial Services (DIFS).
How to file a complaint with DIFS
If working directly with the health carrier doesn't satisfy your concerns, you may wish to file a complaint with DIFS. We will send the health carrier a copy of your complaint and ask them to explain their position. Health carriers are required by law to respond to DIFS. We will review the facts to make sure the health carrier has followed its contract with you and that it has also complied with insurance rules and laws.
Health Coverage Grievances and Appeals
Internal Grievance Process
Under Michigan laws, each health carrier must establish an internal grievance process. This process provides the member or their authorized representative an avenue to seek resolution when there has been an adverse determination.
Patient’s Right to Independent Review Act (PRIRA)
The Patient's Right to Independent Review Act (PRIRA) is a Michigan law that provides patients with appeal rights due to adverse decisions made by health carriers regarding a denial, reduction, or termination of health care services. The PRIRA external review process applies after the patient has exhausted the health carrier's internal grievance process.