What is the name of the health plan/health insurer that dropped, canceled or rescinded coverage?
What is the name of the health plan/health insurer that denied authorization or payment for a medical treatment or procedure?
What is the name of the health plan or health insurer that unreasonably delayed in authorizing or agreeing to pay for a medical treatment or procedure?

< Select Insurer > Aetna Assurant (formerly FORTIS) AXA Blue Cross Blue Shield Cigna CPIC Life Fairmont Globe Health Net Kaiser Metropolitan New York Life Pacificare Prudential Security Life Standard Time

Name of company, if not in above list:

 
What month and year was coverage dropped, canceled or rescinded?
What month and year did it deny or refuse to authorize payment for the medical treatment or procedure?
What month and year did it delay in authorizing or agreeing to pay for a medical treatment or procedure?

< Select Month > January February March April May June July August September October Novermber December Don't Recall     < Select Year > 2008 2007 2006 2005 2004 Pre-2004 Don't Recall
 
In what city, region or state do you (or the person whose coverage was dropped, if different) live?
In what city, region or state do you (or the person who was denied authorization or payment, if different) live?
In what city, region or state do you (or the person whose authorization or payment was delayed, if different) live?

< Select Region > City of Los Angeles County of Los Angeles Southern California (Non-L.A./L.A. County) Other part of California Other State     Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
 
Did the health plan/health insurer claim that it dropped, canceled or rescinded your policy because you submitted an application that contained false, inaccurate or incomplete information about your health?
Yes    No
 
What reason did the health insurer or health plan give for denying authorization or payment for the medical treatment or procedure?
< Select Reason > Treatment was Experimental or Investigatory Treatment was Not Medically Necessary Other

 
  If "Other," please explain:


 
Was your insurance dropped, canceled or rescinded after you or your health care provider had submitted a claim to the health plan/insurer?
Yes    No
 
Did you purchase your health coverage through an agent?
Yes    No

If Yes, please give agent's name:
First Name	Last Name
Address

 
Did you already have other health coverage at the time you purchased the health care plan or health insurance policy that was later dropped, canceled or rescinded?
Yes    No
 
In the box below, you may provide additional information about your experience with having your coverage dropped, canceled or rescinded:
In the box below, you may provide additional information about the situation in which the health insurer or health plan denied authorization or payment for a medical treatment or procedure:
In the box below, you may provide additional information about the situation in which a health insurer or health plan unreasonably delayed in authorizing or agreeing to pay for a medical treatment or procedure:
(maximum 250 words)

 
Your information is crucial to our investigation and your assistance is appreciated.  The value of the information will be greatly enhanced if you provide us with your contact information so that we have the ability to communicate further with you:


First Name	Last Name
Address
Phone Number where we can reach you:
Best time to call you: Day Evening Weekend All
EMail

IMPORTANT NOTICE:
The Office of the Los Angeles City Attorney represents the People of the State of California in criminal and civil law enforcement cases. The Office of the Los Angeles City Attorney cannot represent you individually, nor can we refer you to a private attorney for representation. This website is intended solely to gather information for a law enforcement investigation regarding potentially unlawful, fraudulent or unfair business practices of health care plans and health care insurers. If you choose to provide information on this website, it may be used for law enforcement purposes, including all legal proceedings that may result from this investigation. During the course of the investigation, we will make every reasonable effort to maintain the privacy and confidentiality of the information you provide. However, in the event that a civil or criminal case is filed against the health care plan or health insurer that is the subject of your complaint, it may be necessary to disclose your information in the resulting court proceedings.

If you are currently represented by a private attorney in a dispute against a health care plan or health insurer, we urge you to consult with your attorney before providing us with the information requested above.

If you are having problems with your health insurance or health plan, you have the ability to file a complaint with and seek assistance from the California Department of Insurance or the California Department of Managed Health Care. These regulatory agencies are separate and distinct from the Los Angeles City Attorney’s Office. Providing information to us through this website will not constitute filing a complaint with the Department of Insurance or the Department of Managed Health Care.

 I have read and I understand this notice, and I am voluntarily providing the
       information submitted herewith to the Office of the Los Angeles City Attorney.