What should I do if I have a complaint about my health plan?

You have many rights and protections when it comes to health plans, especially if your plan is an HMO. (To learn the difference between types of plans, go to What type of health plan is best for me?). Until recently, though, there were few ways to get your problems solved without going to court.

The California Medical Association has worked to make it possible for patients to solve their problems with health service plans, including HMOs, in a faster, less complicated way. We sponsored a law that lays out grievance procedures that can be used for any concern, for example a charge that your health plan refused to pay or an instance when you had to wait an unreasonably long time to see a doctor.

These instructions will take you through the process of filing a complaint and tell you what to expect along the way. You'll want to follow somewhat different guidelines if your problem is an emergency.

The first step is to tell your health plan about your problem in writing. We suggest that you:

Write your letter as soon as possible, while all the facts are still fresh in your mind.

Explain the situation in a brief, clear way, including facts (names, dates, places, etc.) whenever possible.

Tell your plan exactly what you want them to do to solve the problem.

Include copies of any papers that relate to the problem (statements, checks, etc.)

Try to stick to the facts and avoid exaggerating.

Here is a sample letter you may wish to use as a guide:

DRAFT Sample Letter of Complaint with Health Plan

Alternatively, you can file a complaint on-line - just