Section 632.83. Internal grievance procedure.

 

(1)  In this section, “health benefit plan" has the meaning given in s. 632.745 (11) , except that “health benefit plan" includes the coverage specified in s. 632.745 (11) (b) 10. and includes a policy, certificate or contract under s. 632.745 (11) (b) 9. that provides only limited-scope dental or vision benefits.

(2)  Every insurer that issues a health benefit plan shall do all of the following:

(a) Establish and use an internal grievance procedure that is approved by the commissioner and that complies with sub. (3) for the resolution of insureds' grievances with the health benefit plan.

(b) Provide insureds with complete and understandable information describing the internal grievance procedure under par. (a) .

(c) Submit an annual report to the commissioner describing the internal grievance procedure under par. (a) and summarizing the experience under the procedure for the year.

(3)  The internal grievance procedure established under sub. (2) (a) shall include all of the following elements:

(a) The opportunity for an insured to submit a written grievance in any form.

(b) Establishment of a grievance panel for the investigation of each grievance submitted under par. (a) , consisting of at least one individual authorized to take corrective action on the grievance and at least one insured other than the grievant, if an insured is available to serve on the grievance panel.

(c) Prompt investigation of each grievance submitted under par. (a) .

(d) Notification to each grievant of the disposition of his or her grievance and of any corrective action taken on the grievance.

(e) Retention of records pertaining to each grievance for at least 3 years after the date of notification under par. (d) .

1999 a. 155 ss. 8 to 17 ; Stats. 1999 s. 632.83.