The Rights of Persons Covered by Health Insurance

Michigan law also assures individuals the right to receive important information about their health insurance coverage. This law applies to state-regulated health insurance companies, health maintenance organizations (HMO), preferred provider organizations (PPO), and Blue Cross Blue Shield of Michigan.

A health insurer must provide persons whom it covers with the following information:

• Which services are included in the health care coverage plan?
  
• How much an individual patient will have to pay for services?
  
• Who can an individual call to file a complaint?
  
• How does the insurance plan handle coverage for emergencies?
  
• What happens if a person’s family physician no longer participates in that insurance plan?
  
• What happens if a person needs treatment while out of state or out of the covered service area?

If you did not get this information, you should contact your insurance company and ask for this important material.

State law offers special protection to individuals covered by a health care plan that requires selection of a physician from an approved list of health professionals (i.e. most HMOs and similar plans). A person enrolled in an HMO, or similar health plan, has the right to information about:

• The qualifications of doctors available to provide treatment.
  
• The services that require advance approval
  
• The coverage for prescription drugs
  
• The way that the health plan pays for services

Under the law, your HMO must provide you with the name, address, and phone number of a person to contact for more information about the issues listed above. If you do not know whom to contact, call the HMO and ask to be connected with someone who can give you further information.

You also should be aware of other state laws related to health care and health insurance coverage. A health insurance plan cannot ask a physician to sign a contract that stops that doctor from telling patients about all of their medical options and rights. Additionally, the insurance company must guarantee health coverage without pre-approval, if a patient has a medical emergency.

Finally, the Michigan law, MCL 550.1907-15, known as the Patient’s Right To Independent Review Act, provides an appeal process, if a health insurance company refuses to pay for necessary medical treatment that an individual believes should be covered.

The process has three steps:

1. The insurance company must give the person prompt written notice of the dispute.
   
2. The health insurer must review its decision to deny benefits, if the individual requests it.
   
3. If the insurance company continues to refuse payment for the treatment, or fails to review the initial negative decision, the patient has the right to file an appeal with the state Office of Financial and Insurance Services. (This is the last step in the appeal process, because current state law does not give a patient to file a lawsuit against the health care plan.)

Protect your rights.

If you or a loved one is the victim of medical malpractice, talk with an experienced Michigan medical malpractice lawyer. Please submit a simple, free and confidential legal consultation form now.

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