Subchapter II — Grievance Procedures
Ins 18.04 Right of the commissioner to request OCI complaints be handled as grievances. Ins 18.05 Expedited grievance procedure. Ins 18.06 Reporting requirements. Subchapter III — Independent Review Procedures
Ins 18.105 Annual CPI adjustment for independent review eligibility. Ins 18.11 Independent review. Ins 18.12 Independent review organization procedures. Ins 18.13 Standards of independent review. Ins 18.14 Approval of independent review organizations. Ins 18.16 Independent review organization reporting requirements. Ins 18.18 Independent review organization fees. Ins 18.01Ins 18.01 Definitions. In this chapter: Ins 18.01(1)(1) “Commissioner” means the “commissioner of insurance” of this state or the commissioner’s designee. Ins 18.01(2)(2) “Complaint” means any expression of dissatisfaction expressed to the insurer by the insured, or an insured’s authorized representative, about an insurer or its providers with whom the insurer has a direct or indirect contract. Ins 18.01(2m)(2m) “Coverage denial determination” has the meaning as defined in s. 632.835 (1) (ag), Stats., and includes, for individual insurance products, a policy reformation or change in premium charged based upon underwriting or claims information greater than 25% from the premium in effect during the period of contestability except to the extent the modification is due to the applicant’s age or a rate increase applied by the insurer to all similar individual policy forms applied uniformly. Ins 18.01(3)(3) “Expedited grievance” means a grievance where any of the following applies: Ins 18.01(3)(a)(a) The duration of the standard resolution process will result in serious jeopardy to the life or health of the insured or the ability of the insured to regain maximum function. Ins 18.01(3)(b)(b) In the opinion of a physician with knowledge of the insured’s medical condition, the insured is subject to severe pain that cannot be adequately managed without the care or treatment that is the subject of the grievance. Ins 18.01(3)(c)(c) A physician with knowledge of the insured’s medical condition determines that the grievance shall be treated as an expedited grievance. Ins 18.01(4)(4) “Grievance” means any dissatisfaction with an insurer offering a health benefit plan or administration of a health benefit plan by the insurer that is expressed in writing to the insurer by, or on behalf of, an insured including any of the following: