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Washington State Office of the Insurance Commissioner

Patient's Bill of Rights

About the Patient's Bill of Rights

How the Patient's Bill of Rights protects you

Appealing a denial or filing a grievance

About the Patient's Bill of rights

Washington state's Patients' Bill of Rights guarantees health insurance consumers access to quality health care.

Under the Patients' Bill of Rights, you:

  • Are guaranteed that health-care decisions providers make are based on medical standards.
  • Have better access to information about your health insurance plans.
  • Have access to a quick and impartial process for appealing denials of health coverage.
  • Have the right to independent third-party reviews when your insurer denies coverage.
  • Are protected from unneeded invasions of privacy.
  • Can ask for damages that result when managed care insurers withhold or deny you appropriate care.

How the Patients' Bill of Rights protects you

Accessing providers

Your health plan must allow you to choose a primary health care provider from a list of participating providers, change providers, and provide you with prompt and appropriate referrals to specialists. If you have a complex or serious condition, your health plan may even give you a standing referral to a specialist. Also, if your plan covers chiropractic care, it must allow you direct access to a chiropractor.

Protecting your privacy

Health insurers and providers cannot disclose your personal information, including your health records, unless you give them explicit authority in writing to do so.

Receiving benefits

Before you buy any health plan, it must provide you with a list of covered benefits, including prescription drug coverage. It also must tell you any exclusions, limitations, or reductions in coverage. This includes any factors it considers when determining what is a covered service. Before you buy a health plan, it must disclose the following:

  • How the plan protects your confidentiality.
  • The premium and other costs.
  • How to file a grievance.
  • The amount you need to pay for services, such as copays, deductibles, or coinsurance.
  • Participating providers.

The health plans also must make additional information describing the plan and its operations available to you upon request — whether you are a prospective enrollee or a current enrollee.

Appealing a denial or filing a grievance

Health plans must have a grievance process in place that allows you to appeal any claim denial. The process must be prompt, fair, and impartial. Your plan also should send you timely notice of the outcome, and information about further appeals or independent third-party reviews. To find out more about the appeals process, check out our appeals guide.

How to get an independent third-party review of your appeal

If you are an enrollee and your health plan denies you health coverage, you can ask for an independent third-party review. Your plan must develop a process for appealing and the results of the review are binding.

Seeking damages that result from denial of care

Health plans and their employees and agents must follow accepted standards of care when they make health care treatment decisions. If they fail to follow accepted standards of care, in some cases, you can sue for damages, depending upon the type of coverage you have.

However, prior to any legal action against a health plan, you must get an independent review. Generally, if you are covered by individually purchased health plans, you can sue under Washington state law. If you are enrolled in a group employee benefit plan, these are often subject to other laws that restrict suing.

For more information on insurer liability and group health plans, call us at 1-800-562-6900 or the U.S. Department of Labor at 1-866-444-3272.




Updated 04/26/2011

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Need more help? Call our FREE Insurance Consumer Hotline at 1-800-562-6900
or Email us at cap@oic.wa.gov.