Where to Complain about health insurance coverage in California

 I am having a problem with my health insurance company and a medical foundation. I have a PPO (for Preferred Provider Organization) plan.

I had my annual exam in December. In February, the insurance company paid part of the charges but denied the Pap smear and lab fee. I did not realize this until August, when I was billed.

On their Explanation of Benefits, the insurance company said that my plan does not cover the charges for the Pap smear and lab work. This is nonsense.

I called the insurance company in September, and a very helpful woman told me that it was the company's error, and she would see that it was fixed within 10 business days. Just days ago, I received another bill for the same amount. Visiting the insurance company Web site, I find that they have not paid the claim.

I am about to write to the insurance company and the medical group for a second time, in more forceful terms. If both continue to ignore me, to whom should I complain?

A In general, with a PPO helath insurance plan, one can see any doctor one wishes, or visit any hospital one chooses, usually within a preferred network of providers. Depending upon the terms of coverage, a doctor or hospital outside the preferred provider list will cost more and the PPO will pay a range of 70 percent to 80 percent of expenses.

Conversely, an HMO (health maintenance organization) generally requires one see only doctors or hospitals on their list of providers.

For complaints about PPOs, a good place to start and mention in your letter, Caroline, is the California Department of Insurance. You can file a complaint at www.insurance.ca.gov/contact-us/0200-file-complaint.

You can also get information by phone at the Department of Insurance Consumer Hotline at 800-927-4357.

Or, if your insurance is with an HMO, contact the California Department of Managed Health Care at www.hmohelp.ca.gov or call the help center at 1-888-466-2219.