§33-25C-5. Enrollee complaints; internal grievance procedure.
(a) Each managed care plan must establish and maintain an
internal grievance procedure for the fair consideration of disputes
relating to any provisions of the plan's contract, including, but
not limited to, claims regarding the scope of coverage for health
care services; denials, cancellations or nonrenewals of enrollee
coverage; observance of an enrollee's rights as a patient; the
quality of health care services; or decisions by managed care plans
to deny, modify, reduce, or terminate coverage of or payment for
health care services for an enrollee, as more specifically set
forth in section twelve, article twenty-five-a, chapter
thirty-three of this code.
(b) Except for determinations of whether a health care service
is medically necessary, or determinations of whether a health care
service is experimental, an enrollee may appeal the final decision
resulting from the internal grievance procedure to the insurance
commissioner, as set forth in section twelve, article
twenty-five-a, chapter thirty-three of this code.
(c) Any party aggrieved by an order of the insurance
commissioner may appeal to the circuit court of Kanawha County, as
set forth in section fourteen, article two, chapter thirty-three.
The judgment of the circuit court may be reviewed upon appeal by
the supreme court of appeals in the same manner as other civil cases to which the state is a party.