Last updated on: 10/24/2012 9:04:27 AM PST
Does Obamacare Allow Individuals to Appeal Medical Service Denials? – YES
General Reference (not clearly pro or con)
The Patient Protection and Affordable Care Act, Section 2719, page 19, "Appeals Process," signed into law on Mar. 23, 2010, available at the Library of Congress website, states:
"A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum—
(1) have in effect an internal claims appeal process;
(2) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 2793 to assist such enrollees with the appeals processes; and
(3) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process."
Mar. 23, 2010 - Patient Protection and Affordable Care Act (HR 3590) (2MB)
The US Department of Health and Human Services stated in its June 15, 2012 posting "Has Your Health Insurer Denied Payment for a Medical Service? You Have a Right to Appeal," available at the Affordable Care Act website:
"The Affordable Care Act, the health care reform law passed in 2010, requires many health plans to meet basic standards regarding internal appeals and external review processes...
- Right to information about why a claim or coverage has been denied. Health plans and insurance companies have to tell you why they've decided to deny a claim or chosen to end your coverage. They have to let you know how you can dispute decisions.
- Right to appeal to the insurance company. If you've had a claim denied or had your health insurance coverage cancelled or rescinded back to the date you initially enrolled, you have the right to an internal appeals process. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process.
- Right to an independent review. In many cases, you may be able to resolve your problem during the internal appeals process with your insurer. But you have other options if you can't work it out through the internal appeals process. You now have the right to take your appeal to an independent third-party for review of the insurer's decision. This is called 'external review.' External review means that the insurance company no longer gets the final say over many benefit decisions. It also means patients and doctors have more control over health care."
The Federal Registrar stated on its webpage "Internal Claims, Appeals, and External Review Processes Under the Affordable Care Act," available at its website (last updated Feb. 11, 2011):
"The Affordable Care Act provides consumers with the right to appeal decisions made by their health carrier to an outside, independent decision maker, regardless of the State of residence or type of health insurance. Under interim final regulations issued earlier this year, non-grandfathered plans and issuers must comply with a State external review process or the Federal external review process."
[Editor's Note: Based upon a neutral reading of the Patient Protection and Affordable Care Act and bi-partisan third party analysis, this question seems to have a clear and obvious Pro (yes) answer, and ProCon.org has therefore presented the responses in a single column with no opposing perspective.]