You've got cancer and your insurer says your chosen treatment is too experimental. Or your toddler has been diagnosed as autistic, but your insurance company says his behavioral therapy is medically unnecessary.
If an insurer denies a medical treatment or claim, you're entitled to an independent review of that decision.
Thousands of Californians have taken advantage of those Independent Medical Reviews, or IMRs, in the last decade. But with changes in health care laws both nationally and in California, the state wants more consumers to know their rights.
"There's a lot of tumult in the health care market right now and significant incentives for health insurers to look for ways to cut costs" by denying treatments or claims, said state Insurance Commissioner Dave Jones, whose department oversees about 2 million Californians who buy individual health policies.
"I suspect there are people who are not aware they have this option. Some people give up. That's why we're trying to get the word out."
This week, the state Department of Insurance will be reminding insurers that they must provide a clear, written explanation of why they're denying coverage or claims for medical treatment. And it's also reminding consumers that they have a right to challenge those denials.
Among those are Jerry and Libbie Moeckel, Bay Area parents of an autistic 12-year-old son, who successfully fought their insurance company's denial of his behavioral therapy.
Years after his diagnosis at age 2, their son Ethan began struggling with behaviorial issues that kept him out of a regular classroom. Libbie began home-schooling Ethan while searching for autism therapies that could help him.
Last January, after getting approval for 10 hours a week of intensive behavioral therapy, a recognized treatment for children with autism, the Moeckels requested insurance coverage for the $500 to $600 weekly cost. It was denied as medically unnecessary.
Their case was submitted for an IMR in April. In May, just two months before new legislation, SB 946, made behavioral therapy for autistic children a mandatory category of insurance coverage in California, the IMR ruled in their favor. Ethan's weekly treatment was cleared.
"It was like a weight lifted off my shoulders," said Libbie Moeckel. The Oakley couple also have a 14-year-old daughter.
Both the state insurance department and the Department of Managed Health Care are on a mission to get the word out for families like the Moeckels.
While autism treatment cases have flared up in recent years, the IMR process is available to anyone with any medical issue, whether it be cancer, diabetes or heart disease.
"If a consumer receives an insurance company's letter and is confused or overwhelmed, call us. We will help walk them through the process," said Marta Green, spokeswoman for the Department of Managed Health Care, which oversees managed health care plans covering 20 million Californians.
In 2011, the DMHC resolved 1,624 IMRs involving the state's nine largest insurers (including Aetna, Anthem Blue Cross, Blue Shield and Kaiser). Of those, 690 decisions by insurers were upheld and 640 were overturned. Another 294 were withdrawn by the insurer before the IMR process was completed, meaning the insurer withdrew its denial.
Ideally, consumers should first file an appeal with their health insurer. If unsuccessful in getting a decision overturned, the next step is to seek an IMR through the DMHC if you are in an HMO or similar managed care plan, typically through an employer; or via the state Department of Insurance if you buy your policy directly from an insurance company.
A spokeswoman for a statewide insurers group says health care providers carefully render their medical treatment decisions, but welcome the option of an independent review.
"Health plans have been supportive of the IMR process since it begin in California. It means there's a place for consumers to go when they're not happy with a decision the insurer makes," said Nicole Evans, spokeswoman for the California Association of Health Plans, which represents 39 health insurance plans offering HMO and other group plan coverage to Californians.
For the Moeckels, getting insurance coverage for their son's weekly sessions with an in-home autism therapist was life-changing.
Six months after the insurance coverage started, Libbie was able to return to work and Ethan now attends an autism classroom at a Bay Area public middle school.
"This is huge. He's in school and it's putting him back on track for future independence in life," said Libbie. "I can't tell you how much of a lifesaver it has been."
WHAT'S AN IMR?
Consumers have the right to appeal their insurer's denial of a medical treatment or claim. Officially called an Independent Medical Review, it is conducted by a doctor (or a panel of doctors) overseen by state health care regulators.
An IMR can be filed if an insurer:
Denies, delays or modifies treatment as "medically unnecessary";
Denies coverage of what it deems "experimental" or unproven therapies;
Denies coverage for urgent/emergency services.
HOW IT WORKS
In most cases, patients must first file an appeal with their insurance company over the denied treatment or claim. If unsatisfied with the response, patients can seek an IMR.
Most reviews are completed within 30 days. If the review overturns the insurer's decision, the treatment or service must be covered.
WHERE TO GET HELP
If you have an individual insurance plan (not covered by an employer or labor union), contact the state Department of Insurance: Call (800) 927-HELP (4357) or go to: www.insurance.ca.gov (search under "Consumers."
If you're covered by an HMO or other group insurance plan, contact the state Department of Managed Health Care: Call (888) 466-2219 or go to www.hmohelp.ca.gov (search under "Problems & Complaints").