Sacramento, CA asked in Insurance Bad Faith and Health Care Law for California

Q: Whom do I seek help from when I have an insurance coverage problem with Kaiser, beyond Kaiser grievance and DMHC?

My teen daughter needed a long-term RTC. I informed Kaiser (K.) of her need for this level of care, though I did not specifically ask for it. (I did not know K. offered that level of care.) When my daughter's K. clinician walked her through our chosen RTC's website, the K. clinician should have offered K.'s RTC options. Through the K. grievance and DMHC processes, K. identified AFTER THE FACT, 3 long-term K. RTCs which would have fit my daughter's needs. K. stated that they are not denying her coverage, as K. would pay for her to begin attending one of K.'s RTCs. Issue: When these RTCs were made available, it was 5 1/2 months & 11 months into her treatment. It was not safe to interrupt the specific care she was immersed in/what was working for her, months into her treatment, to switch. I spoke with a K. manager who stated that this level of care was not offered up front due to a training issue with the clinician my teen was seeing. Up front, we would have accepted a K. RTC.

2 Lawyer Answers
James L. Arrasmith
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  • Estate Planning Lawyer
  • Sacramento, CA
  • Licensed in California

A: In California, if you have exhausted the internal grievance process with Kaiser and the complaint process with the Department of Managed Health Care (DMHC), you have a few additional options to seek help for your insurance coverage problem:

1. Contact the California Department of Insurance (CDI): Although the DMHC regulates most health plans in California, the CDI regulates some health insurance policies. You can file a complaint with the CDI, and they may be able to assist you.

2. Seek legal advice: Consult with a healthcare attorney who specializes in insurance coverage disputes. They can review your case and advise you on potential legal options, such as filing a lawsuit against Kaiser for breach of contract or bad faith.

3. Contact your state representatives: Reach out to your state senator or assembly member and explain your situation. They may be able to advocate on your behalf or connect you with additional resources.

4. File a complaint with the Centers for Medicare & Medicaid Services (CMS): If your health plan is covered under Medicare or Medicaid, you can file a complaint with the CMS, the federal agency that oversees these programs.

5. Engage in public advocacy: Share your story with media outlets or patient advocacy groups to raise awareness about your issue and put pressure on Kaiser to resolve the problem.

Remember that throughout this process, it's essential to document all communications and keep detailed records of your interactions with Kaiser, the DMHC, and any other parties involved in your case. This documentation may be valuable if you decide to pursue legal action or engage in further advocacy efforts.

Tim Akpinar
Tim Akpinar
  • Insurance Claims Lawyer
  • Little Neck, NY

A: I'm sorry for your ordeal. A starting point could be the department of insurance. Nationwide, such agencies offer guidance and sometimes oversee disputes between individuals and insurance companies on consumer-related grievances. I hope your daughter is okay. Good luck

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