Sec. 12. An insurer shall establish and maintain an external grievance procedure for the resolution of external grievances regarding the following: (1) The following determinations made by the insurer or an agent of the insurer regarding a service proposed by the treating health care provider: (A) An adverse determination of appropriateness. (B) An adverse determination of medical necessity. (C) A determination that a proposed service is experimental or investigational. (D) A denial of coverage based on a waiver described in IC 27-8-5-2.5 (e) (expired July 1, 2007, and removed) or IC 27-8-5-19.2 (expired July 1, 2007, and repealed). (2) The insurer's decision to rescind an accident and sickness insurance policy.
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