CHAPTER 28. INTERNAL GRIEVANCE PROCEDURES
IC 27-8-28
Chapter 28. Internal Grievance Procedures
IC 27-8-28-1
"Accident and sickness insurance policy" defined
Sec. 1. (a) As used in this chapter, "accident and sickness
insurance policy" means an insurance policy that provides one (1) or
more of the kinds of insurance described in Class 1(b) and 2(a) of
IC 27-1-5-1.
(b) The term does not include the following:
(1) Accident only, credit, dental, vision, Medicare supplement,
long term care, or disability income insurance.
(2) Coverage issued as a supplement to liability insurance.
(3) Automobile medical payment insurance.
(4) A specified disease policy issued as an individual policy.
(5) A limited benefit health insurance policy issued as an
individual policy.
(6) A short term insurance plan that:
(A) may not be renewed; and
(B) has a duration of not more than six (6) months.
(7) A policy that provides a stipulated daily, weekly, or monthly
payment to an insured during hospital confinement without
regard to the actual expense of the confinement.
(8) Worker's compensation or similar insurance.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-2
"Commissioner" defined
Sec. 2. As used in this chapter, "commissioner" refers to the
insurance commissioner appointed under IC 27-1-1-2.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
Amended by P.L.1-2002, SEC.113.
IC 27-8-28-3
"Covered individual" defined
Sec. 3. As used in this chapter, "covered individual" means an
individual who is covered under an accident and sickness insurance
policy.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-4
"Department" defined
Sec. 4. As used in this chapter, "department" refers to the
department of insurance.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-5
"External grievance" defined
Sec. 5. As used in this chapter, "external grievance" means the
independent review under IC 27-8-29 of a grievance filed under this
chapter.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-6
"Grievance" defined
Sec. 6. As used in this chapter, "grievance" means any
dissatisfaction expressed by or on behalf of a covered individual
regarding:
(1) a determination that a service or proposed service is not
appropriate or medically necessary;
(2) a determination that a service or proposed service is
experimental or investigational;
(3) the availability of participating providers;
(4) the handling or payment of claims for health care services;
or
(5) matters pertaining to the contractual relationship between:
(A) a covered individual and an insurer; or
(B) a group policyholder and an insurer;
and for which the covered individual has a reasonable expectation
that action will be taken to resolve or reconsider the matter that is the
subject of dissatisfaction.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
Amended by P.L.1-2002, SEC.114.
IC 27-8-28-7
"Grievance procedure" defined
Sec. 7. As used in this chapter, "grievance procedure" means a
written procedure established and maintained by an insurer for filing,
investigating, and resolving grievances and appeals.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-8
"Insured" defined
Sec. 8. As used in this chapter, "insured" means:
(1) an individual whose employment status or other status
except family dependency is the basis for coverage under a
group accident and sickness insurance policy; or
(2) in the case of an individual accident and sickness insurance
policy, the individual in whose name the policy is issued.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-9
"Insurer" defined
Sec. 9. As used in this chapter, "insurer" means any person who
delivers or issues for delivery an accident and sickness insurance
policy or certificate in Indiana.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-10
Grievance procedure to comply with chapter requirements
Sec. 10. An insurer shall establish and maintain a grievance
procedure that complies with the requirements of this chapter for the
resolution of grievances initiated by a covered individual.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-11
Commissioner may examine procedure
Sec. 11. The commissioner may examine the grievance procedure
of any insurer.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-12
Grievance records
Sec. 12. An insurer shall maintain all grievance records received
by the insurer after the most recent examination of the insurer's
grievance procedure by the commissioner.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-13
Insurer to provide notice to insured
Sec. 13. (a) An insurer shall provide timely, adequate, and
appropriate notice to each insured of:
(1) the grievance procedure required under this chapter;
(2) the external grievance procedure required under IC 27-8-29;
(3) information on how to file:
(A) a grievance under this chapter; and
(B) a request for an external grievance review under
IC 27-8-29; and
(4) a toll free telephone number through which a covered
individual may contact the insurer at no cost to the covered
individual to obtain information and to file grievances.
(b) An insurer shall prominently display on all notices to covered
individuals the toll free telephone number and the address at which
a grievance or request for external grievance review may be filed.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-14
Filing grievance; toll free number
Sec. 14. (a) A covered individual may file a grievance orally or in
writing.
(b) An insurer shall make available to covered individuals a toll
free telephone number through which a grievance may be filed. The
toll free telephone number must:
(1) be staffed by a qualified representative of the insurer;
(2) be available for at least forty (40) hours per week during
normal business hours; and
(3) accept grievances in the languages of the major population
groups served by the insurer.
(c) A grievance is considered to be filed on the first date it is
received, either by telephone or in writing.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-15
Assistance in filing grievance; designation of representative
Sec. 15. (a) An insurer shall establish procedures to assist covered
individuals in filing grievances.
(b) A covered individual may designate a representative to file a
grievance for the covered individual and to represent the covered
individual in a grievance under this chapter.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-16
Policies and procedures for timely resolution of grievances
Sec. 16. (a) An insurer shall establish written policies and
procedures for the timely resolution of grievances filed under this
chapter. The policies and procedures must include the following:
(1) An acknowledgment of the grievance, given orally or in
writing, to the covered individual within five (5) business days
after receipt of the grievance.
(2) Documentation of the substance of the grievance and any
actions taken.
(3) An investigation of the substance of the grievance, including
any aspects involving clinical care.
(4) Notification to the covered individual of the disposition of
the grievance and the right to appeal.
(5) Standards for timeliness in:
(A) responding to grievances; and
(B) providing notice to covered individuals of:
(i) the disposition of the grievance; and
(ii) the right to appeal;
that accommodate the clinical urgency of the situation.
(b) An insurer shall appoint at least one (1) individual to resolve
a grievance.
(c) A grievance must be resolved as expeditiously as possible, but
not more than twenty (20) business days after the insurer receives all
information reasonably necessary to complete the review. If an
insurer is unable to make a decision regarding the grievance within
the twenty (20) day period due to circumstances beyond the insurer's
control, the insurer shall:
(1) before the twentieth business day, notify the covered
individual in writing of the reason for the delay; and
(2) issue a written decision regarding the grievance within an
additional ten (10) business days.
(d) An insurer shall notify a covered individual in writing of the
resolution of a grievance within five (5) business days after
completing an investigation. The grievance resolution notice must
include the following:
(1) A statement of the decision reached by the insurer.
(2) A statement of the reasons, policies, and procedures that are
the basis of the decision.
(3) Notice of the covered individual's right to appeal the
decision.
(4) The department, address, and telephone number through
which a covered individual may contact a qualified
representative to obtain additional information about the
decision or the right to appeal.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
Amended by P.L.1-2002, SEC.115.
IC 27-8-28-17
Policies and procedures for timely resolution of appeals of
grievance decisions; filing of report for violation
Sec. 17. (a) An insurer shall establish written policies and
procedures for the timely resolution of appeals of grievance
decisions. The procedures for registering and responding to oral and
written appeals of grievance decisions must include the following:
(1) Written or oral acknowledgment of the appeal not more than
five (5) business days after the appeal is filed.
(2) Documentation of the substance of the appeal and the
actions taken.
(3) Investigation of the substance of the appeal, including any
aspects of clinical care involved.
(4) Notification to the covered individual:
(A) of the disposition of an appeal; and
(B) that the covered individual may have the right to further
remedies allowed by law.
(5) Standards for timeliness in:
(A) responding to an appeal; and
(B) providing notice to covered individuals of:
(i) the disposition of an appeal; and
(ii) the right to initiate an external grievance review under
IC 27-8-29;
that accommodate the clinical urgency of the situation.
(b) In the case of an appeal of a grievance decision described in
section 6(1) or 6(2) of this chapter, an insurer shall appoint a panel
of one (1) or more qualified individuals to resolve an appeal. The
panel must include one (1) or more individuals who:
(1) have knowledge of the medical condition, procedure, or
treatment at issue;
(2) are licensed in the same profession and have a similar
specialty as the provider who proposed or delivered the health
care procedure, treatment, or service;
(3) are not involved in the matter giving rise to the appeal or in
the initial investigation of the grievance; and
(4) do not have a direct business relationship with the covered
individual or the health care provider who previously
recommended the health care procedure, treatment, or service
giving rise to the grievance.
(c) An appeal of a grievance decision must be resolved:
(1) as expeditiously as possible, reflecting the clinical urgency
of the situation; and
(2) not later than forty-five (45) days after the appeal is filed.
An insurer that violates this subsection commits an unfair and
deceptive act or practice in the business of insurance under
IC 27-4-1-4.
(d) If an insurer violates subsection (c), the insurer shall file a
report with the department during the quarter in which the violation
occurred concerning the insurer's compliance with subsection (c).
The report must include the following:
(1) The number of appealed grievance decisions that were not
resolved as required under subsection (c).
(2) The reason each appeal described in subdivision (1) was not
resolved.
(e) An insurer shall allow a covered individual the opportunity to:
(1) appear in person before; or
(2) if unable to appear in person, otherwise appropriately
communicate with;
the panel appointed under subsection (b).
(f) An insurer shall notify a covered individual in writing of the
resolution of an appeal of a grievance decision within five (5)
business days after completing the investigation. The appeal
resolution notice must include the following:
(1) A statement of the decision reached by the insurer.
(2) A statement of the reasons, policies, and procedures that are
the basis of the decision.
(3) Notice of the covered individual's right to further remedies
allowed by law, including the right to external grievance review
by an independent review organization under IC 27-8-29.
(4) The department, address, and telephone number through
which a covered individual may contact a qualified
representative to obtain more information about the decision or
the right to an external grievance review.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
Amended by P.L.1-2002, SEC.116; P.L.178-2003, SEC.72.
IC 27-8-28-18
Insurer prohibited from taking action
Sec. 18. An insurer may not take action against a provider solely
on the basis that the provider represents a covered individual in a
grievance filed under this chapter.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-19
Filing description of grievance procedure
Sec. 19. (a) An insurer shall each year file with the commissioner
a description of the grievance procedure of the insurer established
under this chapter, including:
(1) the total number of grievances handled through the
procedure during the preceding calendar year;
(2) a compilation of the causes underlying those grievances; and
(3) a summary of the final disposition of those grievances.
(b) The information required by subsection (a) must be filed with
the commissioner on or before March 1 of each year. The
commissioner shall:
(1) make the information required to be filed under this section
available to the public; and
(2) prepare an annual compilation of the data required under
subsection (a) that allows for comparative analysis.
(c) The commissioner may require any additional reports as are
necessary and appropriate for the commissioner to carry out the
commissioner's duties under this article.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.
IC 27-8-28-20
Adoption of rules
Sec. 20. The department may adopt rules under IC 4-22-2 to
implement this chapter.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.