Where should you go if you have a complaint against your insurance company? Dianne Zeitler was inquisitive after injuring her arm while touring around Vienna, Austria.
"My insurance company rejected my claim for emergency surgery twice," recalls Zeitler, a former health-care consultant in Washington, D.C.
She, like many policyholders, had many ways to file a complaint. Should she submit a formal complaint to her insurance company? Should she complain to her state's insurance commissioner? Should she employ a lawyer instead?
"A policyholder has several options when an insurance company chooses not to honor its contract or comply with the law," says Jeff Raizner, a partner at Raizner Slania, a Houston legal practice that specializes in insurance disputes.
Here are the most common ways to express your dissatisfaction with your insurance:
- Contact your insurance representative.
- Submit a formal request to a top executive within the insurance business.
- Request an ombudsman to arbitrate your issue.
- Complain to the state insurance department, which oversees insurers' compliance with state laws and regulations.
- If your policy permits for it, pursue arbitration.
- In court, make a legal claim against the insurance.
Zeitler first selected door number three. She filed a complaint with her insurance company's appeals department, which is reviewed by a third party due to its government-run status. She did, however, hedge her chances by opening door number two. She researched the names of the insurance company's board of directors and executives and sent them a nice letter.
"I included a claim chronology, names and departments with whom I spoke, and copies of the bills," she explains.
Do You Have a Complaint About Your Insurance Company? Begin Here
If you acquired your insurance through an agent, you can request that they serve as an advocate on your behalf.
Corinne Kligmann, a partner at Lift Financial, a financial advising business in South Jordan, Utah, advises that if you are experiencing difficulties collecting payment or have any other issues, your first line of defense should be your local agent.
"Their interests are aligned with yours, not with the insurance company's." They may be a valuable ally and provide a straightforward approach to achieving beneficial outcomes.
Request a meeting with an executive
Before seeking outside aid, you should follow the appeals procedure provided by your insurance company. If your insurance provider does not provide information on the appeals procedure, investigate before filing a complaint with an independent party.
Beighley did just that in a case involving an out-of-network claim for a healthcare provider. He finds that several insurance firms hide appeal options on their websites. For example, consider the CareFirst BlueCross BlueShield appeals procedure.
Appeals must be presented in writing. When filing an appeal, provide the member's name, health plan ID number, claim number, date, and service provider information. You must file an appeal within 180 days of receiving notification of a rejection of benefits.
Make a complaint to an Ombudsman.
Some state insurance authorities have an ombudsman, who can assist in resolving complaints.
According to Lisa Lindsay, executive director of the Private Risk Management Association, an educational non-profit organization, this authority is responsible for protecting individuals and investigating concerns.
"They are there to defend you and act as a watchdog to deal with any emerging problems." If you have not made progress with your agent or agency manager, this is the next stage.
If the ombudsman fails to resolve your issue, try making it public. A social media request for help may get the attention of your insurance provider. According to Rick Sabo, a specialist in insurance and investment fraud who operates an independent financial planning firm and advises, informing other consumers about a company's problem-solving practices might help them avoid that company while seeking for insurance.
Submit a Complaint to State Regulators
The McCarran-Ferguson Act of 1945 freed insurance businesses from federal oversight, resulting in state-level regulation in the US.
To find the right insurance contact in your state, visit the National Association of Insurance Commissioners' website (members are listed here). State insurance departments are responsible for taking official complaints about insurance concerns.
"They will generally conduct an investigation," says Dennis Sawan, a personal injury attorney in Toledo, Ohio. "They will also allow the insurer to explain their point of view on the situation."
After adjudication, the body will either certify that no insurance laws were broken or send any violations to the market conduct division for action.
Complaints to the state insurance department are not guaranteed to be resolved. In Ohio, the insurance department does not require companies to satisfy customers if no laws were violated, even if they think the firm or agent acted unfairly.
The amount of complaints submitted with your state's insurance department is publicly available. The dashboard shows the number of insurance purchased, their cost, and any complaints received.
To calculate the complaint ratio, the department divides the number of complaints by the number of written policies. Complaints against insurance companies tend to increase if they perform poorly.
The National Association of Insurance Commissioners provides a tool for estimating complaint percentages.
McCready Law, a Chicago personal injury law firm, believes that a company's complaint ratio reflects its quality. "Some subpar carriers do not even answer the main phone line," he says.
Submit Your Complaint for Arbitration
If you have been refused coverage, you may be able to seek arbitration.
According to Marc Fitapelli, an attorney with Fitapelli & Kurta in New York, the policy will specify how and where disagreements would be resolved. "Arbitration is becoming more popular." Arbitration is only applicable if the policy explicitly specifies it is necessary. If the policy is silent, the parties must sue in court.
Arbitration is divided into two categories: binding and nonbinding.
Adria Goldman Gross, a MedWise Insurance Advocacy advocate, explains why non-binding arbitration allows you to challenge the arbitrator's decision and initiate a lawsuit. "Usually, insurance companies require binding arbitration on their policies—if they allow any arbitration at all."
Getting a Lawyer
If you have a large, expensive, or complex insurance claim, you may need the help of a professional who is familiar with dealing with insurance companies. It's best to hire an attorney as soon as possible if your claim appears to be going wrong.It Doesn't Always Work
Zeitler's lawsuit ended happily.
"Within two days, I received an email from an executive apologizing profusely," she says. "She stated that she believed they handled the entire claim incorrectly and promised to re-educate the staff involved." In addition, she received a cheque for the whole amount of her claim.
0 Comments