WASHINGTON – The Obama administration took the first step Thursday to guarantee that consumers can appeal to a neutral referee if their health insurance company denies a medical claim.

However, because health insurance and President Barack Obama’s overhaul law are both complicated, the new federal safeguards will not immediately apply to most Americans with private coverage.

The regulations issued Thursday spell out a two-stage process for appeals, administration officials said.

First, consumers will appeal directly to the insurer. If they’re denied a second time, they can go to an independent reviewer whose decision is binding. Health plans must pay the cost of outside appeals, and if they’re overruled, they must cover the disputed claim in full.

Consumers can also use the appeals process if their coverage gets canceled. And the rules provide for expedited decisions in medically urgent circumstances.

Although most health plans already have a system for appeals — and 44 states provide for some form of outside review — the federal rules are more stringent with insurers and friendlier to consumers. For example, a clear explanation is required when a claim is denied.


Starting next year, about 40 million consumers in employer and individual plans will benefit from the new law. That number is expected to grow to as many as 88 million by 2013. About 160 million Americans are covered by workplace policies, and another 17 million buy their coverage directly from an insurer.

Assistant Labor Secretary Phyllis Borzi told reporters the appeals protections don’t apply to health plans that were operating at the time Obama signed the law and are considered “grandfathered.”

Many of those plans are run by large employers who pay their health care costs directly and hire an insurance company to administer the coverage. Officials plan a separate review of the rules that apply to those plans.

States will have until July of next year to bring their insurance laws into line with the new federal regulations.


filed under: