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The California Department of Insurance (“CDI”) receives nearly 9,000 health insurance complaints a year—about 7,000 involve health claims issues. Perhaps as a result, California Insurance Commissioner Dave Jones has issued a Notice to Insurers “reminding them” they are legally obligated to fully disclose to consumers why a claim for treatment has been denied.  According to the California Insurance Code, when insurers deny requested treatment as not a covered benefit they are required to give policyholders the specific provisions in their policy that excludes coverage. In addition, if companies deny coverage for a treatment as not medically necessary, they are required to outline the facts and law on which they based their denial. 

“Consumers have the right to full disclosure by their health insurer as to why they are being denied coverage,” said Commissioner Jones. “That way they can make a fully informed decision about whether they agree with the decision, or whether they want to contest it.” 

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