Summary: About one in five Americans who obtains health coverage from his or her employer is enrolled in a traditional indemnity health plan. In such a plan, members choose their physicians, physicians provide care, and the insurer pays all or some portion of the resulting bills. Indemnity plans, which often require that elective hospitalizations and procedures be authorized before they occur, could refuse to pay, or reduce payment, for a service on the grounds that it was not covered in the insurance contract, was not medically necessary, or was not properly authorized. It is in these instances that disputes between the member and indemnity plan commonly arise. This report reviews complaint and appeal systems in indemnity plans. GAO examines (1) the elements that are considered important to a system for processing indemnity plan members' complaints and appeals, (2) the extent to which indemnity plan complaint and appeal systems contain these elements, and (3) how indemnity plans compare with health maintenance organizations in the extent to which their complaint and appeal systems incorporate recommended elements.
