IC 27-8-29-12: Insurer to establish external grievance procedures

Sec. 12. An insurer shall establish and maintain an external grievance procedure for the resolution of external grievances regarding the following:

(1) The following determinations made by the insurer or an agent of the insurer regarding a service proposed by the treating health care provider:

(A) An adverse determination of appropriateness.

(B) An adverse determination of medical necessity.

(C) A determination that a proposed service is experimental or investigational.

(D) A denial of coverage based on a waiver described in IC 27-8-5-2.5(e) (expired July 1, 2007, and removed) or IC 27-8-5-19.2 (expired July 1, 2007, and repealed).

(2) The insurer's decision to rescind an accident and sickness insurance policy.