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 sicknessinsurance policy" means an insurance policy that provides one (1) ormore of the kinds of insurance described in Class 1(b) and 2(a) ofIC 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 anindividual 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 monthlypayment to an insured during hospital confinement withoutregard 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 theinsurance 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 anindividual who is covered under an accident and sickness insurancepolicy.
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 thedepartment 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 theindependent 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 anydissatisfaction expressed by or on behalf of a covered individualregarding:
(1) a determination that a service or proposed service is notappropriate or medically necessary;
(2) a determination that a service or proposed service isexperimental 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 expectationthat action will be taken to resolve or reconsider the matter that is thesubject 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 awritten 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 statusexcept family dependency is the basis for coverage under agroup accident and sickness insurance policy; or
(2) in the case of an individual accident and sickness insurancepolicy, 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 whodelivers or issues for delivery an accident and sickness insurancepolicy 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 grievanceprocedure that complies with the requirements of this chapter for theresolution 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 procedureof 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 receivedby the insurer after the most recent examination of the insurer'sgrievance 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, andappropriate 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 underIC 27-8-29; and
(4) a toll free telephone number through which a coveredindividual may contact the insurer at no cost to the coveredindividual to obtain information and to file grievances.
(b) An insurer shall prominently display on all notices to coveredindividuals the toll free telephone number and the address at whicha 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 inwriting.
(b) An insurer shall make available to covered individuals a tollfree telephone number through which a grievance may be filed. Thetoll 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 duringnormal business hours; and
(3) accept grievances in the languages of the major populationgroups served by the insurer.
(c) A grievance is considered to be filed on the first date it isreceived, 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 coveredindividuals in filing grievances.
(b) A covered individual may designate a representative to file agrievance for the covered individual and to represent the coveredindividual 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 andprocedures for the timely resolution of grievances filed under thischapter. The policies and procedures must include the following:
(1) An acknowledgment of the grievance, given orally or inwriting, to the covered individual within five (5) business daysafter receipt of the grievance.
(2) Documentation of the substance of the grievance and anyactions taken.
(3) An investigation of the substance of the grievance, includingany aspects involving clinical care.
(4) Notification to the covered individual of the disposition ofthe 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 resolvea grievance.
(c) A grievance must be resolved as expeditiously as possible, butnot more than twenty (20) business days after the insurer receives allinformation reasonably necessary to complete the review. If aninsurer is unable to make a decision regarding the grievance withinthe twenty (20) day period due to circumstances beyond the insurer'scontrol, the insurer shall:
(1) before the twentieth business day, notify the coveredindividual in writing of the reason for the delay; and
(2) issue a written decision regarding the grievance within anadditional ten (10) business days.
(d) An insurer shall notify a covered individual in writing of theresolution of a grievance within five (5) business days aftercompleting an investigation. The grievance resolution notice mustinclude the following:
(1) A statement of the decision reached by the insurer.
(2) A statement of the reasons, policies, and procedures that arethe basis of the decision. (3) Notice of the covered individual's right to appeal thedecision.
(4) The department, address, and telephone number throughwhich a covered individual may contact a qualifiedrepresentative to obtain additional information about thedecision 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 ofgrievance decisions; filing of report for violation
Sec. 17. (a) An insurer shall establish written policies andprocedures for the timely resolution of appeals of grievancedecisions. The procedures for registering and responding to oral andwritten appeals of grievance decisions must include the following:
(1) Written or oral acknowledgment of the appeal not more thanfive (5) business days after the appeal is filed.
(2) Documentation of the substance of the appeal and theactions taken.
(3) Investigation of the substance of the appeal, including anyaspects 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 furtherremedies 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 underIC 27-8-29;
that accommodate the clinical urgency of the situation.
(b) In the case of an appeal of a grievance decision described insection 6(1) or 6(2) of this chapter, an insurer shall appoint a panelof one (1) or more qualified individuals to resolve an appeal. Thepanel must include one (1) or more individuals who:
(1) have knowledge of the medical condition, procedure, ortreatment at issue;
(2) are licensed in the same profession and have a similarspecialty as the provider who proposed or delivered the healthcare procedure, treatment, or service;
(3) are not involved in the matter giving rise to the appeal or inthe initial investigation of the grievance; and
(4) do not have a direct business relationship with the coveredindividual or the health care provider who previouslyrecommended the health care procedure, treatment, or servicegiving 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 anddeceptive act or practice in the business of insurance underIC 27-4-1-4.
(d) If an insurer violates subsection (c), the insurer shall file areport with the department during the quarter in which the violationoccurred concerning the insurer's compliance with subsection (c).The report must include the following:
(1) The number of appealed grievance decisions that were notresolved as required under subsection (c).
(2) The reason each appeal described in subdivision (1) was notresolved.
(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 appropriatelycommunicate with;
the panel appointed under subsection (b).
(f) An insurer shall notify a covered individual in writing of theresolution of an appeal of a grievance decision within five (5)business days after completing the investigation. The appealresolution 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 arethe basis of the decision.
(3) Notice of the covered individual's right to further remediesallowed by law, including the right to external grievance reviewby an independent review organization under IC 27-8-29.
(4) The department, address, and telephone number throughwhich a covered individual may contact a qualifiedrepresentative to obtain more information about the decision orthe 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 solelyon the basis that the provider represents a covered individual in agrievance 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 commissionera description of the grievance procedure of the insurer establishedunder this chapter, including:
(1) the total number of grievances handled through theprocedure 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 withthe commissioner on or before March 1 of each year. Thecommissioner shall:
(1) make the information required to be filed under this sectionavailable to the public; and
(2) prepare an annual compilation of the data required undersubsection (a) that allows for comparative analysis.
(c) The commissioner may require any additional reports as arenecessary and appropriate for the commissioner to carry out thecommissioner'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 toimplement this chapter.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13.