Appeal and Grievance Information for California

Insured’s Right to Appeal - California

You have the right to appeal the adverse decision or designate a representative to appeal for you. The following information describes the appeal procedure.

Appeal Request

Assurant Health allows you, your provider, or facility rendering services 180 calendar days after the receipt of the adverse decision to request a
Level I appeal.
  • Include in your request any additional medical information that you feel is pertinent to your case.1
  • We will send you written acknowledgement of your request.
  • The Appeal review will be completed and written notification of the decision will be sent to you within thirty (30) calendar days of initiation of the appeal process.
  • Send the request either in writing, by fax or telephone to:

Assurant Health
Health Management Appeals Department
PO Box 624
Milwaukee, WI  53201
Telephone:  800-454-5105, ext. 6239
Attention:  Health Management Appeals Department

The Assurant Health appeals process will be exhausted upon completion of the Appeal decision.

Plans subject to Health Care Reform

Upon request, you may have reasonable access to all documents, records and other information relevant to your claim or request for benefits and obtain a copy of such information free of charge.

Additionally, you may be entitled to appeal notices in a language other than English.  Contact Assurant Health if you need accommodations for non-English languages.

Independent Review Process

If you are dissatisfied with the internal Appeal decision, you have the right to file a request for Independent Review if an adverse decision was rendered.

The independent review process cannot be used for a Assurant Health decision that is based on a coverage issue. Only decisions regarding a disputed health care service as it relates to the practice of medicine, that do not involve a coverage issue are qualified for the independent review process.

You may seek independent review if health care services have been denied, modified, or delayed by Assurant Health if the decision was based in whole or in part on a finding that the health care service was not medically necessary. You may also seek independent review of experimental or investigational coverage decisions when all of the following criteria are met:
  • You have a life-threatening or seriously debilitating condition.
  • Your physician certifies that you have such a condition:
a) for which standard therapies have not been effective in improving your condition; 
b) for which standard therapies would not be medically appropriate for you; or 
c) for which there is no more beneficial standard therapy covered by Assurant Health than the therapy proposed.
  • You or your physician who is a licensed, board-certified or board-eligible physician qualified to practice in the area of practice appropriate to treat your condition, has requested a therapy that, based on two documents from the medical and scientific evidence is likely to be more beneficial for you than any available standard therapy. The physician certification shall include a statement of the evidence relied upon by the physician in certifying his or her recommendation.
  • You have been denied coverage by Assurant Health for a drug, device, procedure, or other therapy recommended or requested.
  • The specific drug, device, procedure, or other therapy recommended would be a covered service, except for Assurant Health's determination that the therapy is experimental or investigational.

In most cases, it is necessary to go through the internal Assurant Health appeals process prior to requesting an Independent Review.  If Assurant Health upholds its decision on appeal or has not provided a ruling within 30 business days of filing the internal appeal, you can file the Independent Review request.
You must request an Independent Review within six (6) months of any of the qualifying events listed above.

To request an Independent Review:
  1. complete and endorse the application for Independent Review 
  2. provide any documentation referenced in the application 
  3. return all documentation to the Department of Insurance
The Department of Insurance will determine if you are eligible and notify you of assignment of an Independent Review Organization ("IRO") or reasons you may not be eligible.  If an IRO is assigned, it is required to complete its review within 30 days.

Expedited Independent Review

If there is a serious or imminent threat to your health, and your provider or the Department of Insurance certifies in writing that an imminent and serious threat to your health may exist, the IRO must make its determination within three (3) days of receiving the proper case information. In this case, the Department of Insurance may waive the requirement that you first go through the Assurant Health appeals process.

You may contact the California Department of Insurance at any time.

California Department of Insurance
Consumer Communications Bureau
ATTN: Independent Medical Review Program
300 S. Spring Street, South Tower
Los Angeles, CA 90013
800-927-4357 or 213-897-8921

Assurant Health (Time Insurance Company, Union Security Insurance Company & John Alden Life Insurance Company) has maintained the decision that your health care service is not medically necessary, therefore, you have the right to have Independent Medical Review.  Please complete the application for Independent Review and return the application to the California Department of Insurance with any additional information.

Please note that a decision not to participate in the independent review process may cause you to forfeit any statutory right to pursue legal action regarding the disputed health care service.

Please note that you have the right to provide information or documentation, either directly, or through your provider, regarding any of the following:
  • A provider recommendation indicating that the disputed health care service is medically necessary for your medical condition.
  • Medical information or justification that a disputed health care service on an urgent care or emergency basis was medically necessary for your medical condition.
  • Reasonable information supporting your position that the disputed health care service is or was medically necessary for your medical condition.  Include all information provided to you by Assurant Health or a provider concerning Assurant Health's or a provider's decision regarding disputed health care services.  Include a copy of any materials you submitted to Assurant Health in support of the grievance as well as any additional materials that you believe are relevant.

Grievance Process

If you do not agree with a determination, please submit additional information that you would like to have reviewed.  You have 180 days from the date of this letter to submit an appeal for our review.  All pertinent information will be considered and reviewed.  Your correspondence should be directed to us at:  P.O. Box 624, Milwaukee, WI  53201.

Disclaimers
  • No genetic information, including family history should be provided. We do not use or collect genetic information for underwriting purposes. We may; however, request or require a genetic test or family history in order to make a determination regarding payment when the medical necessity or appropriateness of an item or service depends on your genetic makeup.

Diagonal Arrow This icon indicates a link to a website that is not owned or affiliated with Assurant Health. This link is provided for your convenience only, and does not constitute a statement of endorsement, approval, or affiliation or favoring of the external site. Assurant Health is not responsible for the content, views, products or availability of the site, nor does it assume any liability for the accuracy or completeness of its information. Please read our Privacy Policy and Legal Notice for more information.