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how_to_file_a_complaint_against_your_insurance_company [2011/12/28 09:47]
Pat O'Connor [Sample Complaint to State Insurance Commission]
how_to_file_a_complaint_against_your_insurance_company [2012/10/16 14:40] (current)
Line 8: Line 8:
  
 When you plan any [[treatment]],​ whether your have [[leg lymphedema]] or [[arm lymphedema]],​ you will want to study this important page. When you plan any [[treatment]],​ whether your have [[leg lymphedema]] or [[arm lymphedema]],​ you will want to study this important page.
 +
 +[[My Life with Lymphedema and Lymphoma|Pat]]
 +
 +=====Accident and Health Claims=====
 +
 +Be an active partner in you health insurance claim processing process. Insurance companies often need additional medical information or information from you in order to process a claim. If you get requests for information respond in a timely manner and keep a copy of the information sent.
 +
 +If your health insurer or health maintenance organization (HMO) refuses to pay for a recommended or ongoing treatment because the insurer or HMO determined that the treatment was not medically necessary or appropriate your health insurance policy outlines the appeal process you can follow.
 +
 +It’s important when deciding on health insurance to fully understand the provisions of the policy. Although cost may be taken into consideration,​ it’s important to understand what the policy covers. Your agent or your employer should be able to respond to your benefit choices.
 +
 +=====If you have a claim dispute, contact your insurance company first:=====
 + 
 +When contacting your insurance company have your policy number ready. Ask where your written dispute needs to be sent. State your complaint and how you expect the company to resolve it. Sending the dispute in writing encourages a written response.
 + 
 +Document your phone calls by noting the phone number you called, the name of the person with whom you spoke, the date of the call and a brief summary of the conversation. Keep copies of all written communications.
 + 
 +In addition to the written complaint, send copies (not originals) of letters, notes, invoices, canceled checks, advertising materials, or other documents that support your complaint.
 +
 +Be sure you are able to document that you have done everything possible with the insurance company before going to the state insurance commissioner.  ​
 +
 +Involve your physician/s as well.  Many times, you will be able to appeal an insurance company'​s decision with just the medical information your providers can send them.
 +
 +=====Filing a Complaint With Your State Insurance Commissioner=====
 +
 +From Bobbie Sage
 +
 +State insurance commissioners resolve thousands of complaints every year. Complaints vary from disputes with insurance companies about how one's claim was handled to problems with the sale and service of an insurance policy.
 +
 +If you feel your insurance company has not been fair with your claim or policy, you have the right to file a complaint with your state insurance commissioner.
 +
 +If you decide you need to file a complaint, there are a few things you will want to do or be prepared to do. First, go to your state insurance commissioner'​s web site and find out what the processs is to file a complaint. Many state insurance commissioners will have a complaint form available to download or fill out online. Once you know how to start the process, you will want to compile every piece of documentation that pertains to the complaint and start keeping records of all phone conversatins and agent contacts. Most all insurance companies have large claims departments and service call centers where you will almost always speak to a new person each time you contact the company, so it is important for you to keep your own records of all conversaions with the insurance company. Once you have your documents together and know how to file the complaint, it is now time to officially file it.
 +
 +Now that the complaint is filed, your state insurance commissioner'​s office will likely contact you asking for any additional documentation they will need. In most cases the next step the commissioner will take is to send a copy of the complaint to the insurance company and give them a designated response time. Most likely, if the commissioner feels the response is adequate, they will send you a copy of the explanatory letter. But, if the commissioner feels the response from the company is not adequate, your case will probably be taken over by a state designated person that will work with you and the company to resolve the issue and to find out if any laws were broken.
 +
 +One important thing to remember in the complaint process is that even if your case is assigned a state designated person to try to resolve the situation, that person cannot act as your attorney. Depending on what is at stake due to the complaint and your confidence in dealing with the insurance company, hiring an attorney to represent you should always be a consideration.
 +
 +Special thanks
 +
 +[[http://​personalinsure.about.com/​cs/​whattoexpect/​a/​aa031604a.htm|About.com]]
 +
 +=====Sample Complaint to State Insurance Commission=====
 +
 +TODAY’S DATE
 +
 +NAME OF STATE INSURANCE COMMISSION STREET ADDRESS CITY, STATE ZIP CODE
 +
 +Dear Insurance Commissioner:​
 +
 +I have filed the attached insurance claim with NAME OF INSURANCE COMPANY on DATE OF CLAIM. My physician has deemed this therapy medically necessary for my specific condition, but my insurance company has denied me access to the standard of care. I have had the following specific problem(s) with this insurance company:
 +
 +1) EXAMPLE: NAME OF INSURANCE CO. has refused to cover my physician prescribed, medically necessary therapy.
 +2) EXAMPLE: My claim has been neither paid nor denied.
 +3) EXAMPLE: NAME OF INSURANCE CO. has not acknowledged my request for a copy of their policy regarding the therapy my physician has prescribed for me.
 +4) EXAMPLE: In violation of my policy, NAME OF INSURANCE CO. has denied my claim.
 +
 +Please accept this letter as a formal written complaint against NAME OF INSURANCE COMPANY.
 +
 +Sincerely,
 +
 +PATIENT NAME
 +PATIENT ADDRESS
 +CITY, STATE ZIP CODE
 +PHONE #
 +
 +CC: MEDICAL DIRECTOR, NAME OF INSURANCE COMPANY
 +NAME OF PATIENT’S PHYSICIAN
 +National Psoriasis Foundation
 +
 +Enclosures: Insurance Claim
 +ANY OTHER RELEVANT DOCUMENTS (FOR EXAMPLE: LETTER FROM PHYSICIAN, ETC)
 +
 +From: Psoriasis.org
 +Link no longer available
 +
 +=====How to file a complaint against your insurance company - HMO=====
 +
 +FILE AN HMO COMPLAINT
 +Oversight is growing in the HMO marketplace. Should you have a complaint about an HMO practice... report it. We have listed below agencies in each of the 50 states along with a nation HMO accreditation review board. In a growing number of states, HMO complaints are being tallied and are often made public. Employer groups closely evaluate these complaints when determining which HMO contracts to accept each year. You can impact which HMO's will continue practicing in your area. Empowered patients make their voices heard, if you have to resolve your issue are still unhappy with your HMO treatment... file a complaint:
 +
 +The Joint Commission on Acceditation of Healthcare Organizations (JCAHO) wants to know about your complaint. Send the complaint by e-mail, Fax or mail and include the name, street address, city and state of the health care organization.
 +
 +E-Mail: [[complaint@jcaho.org]]
 +
 +Fax: Office of Quality Monitoring
 +(630) 792-5636
 +
 +Mail: Office of Quality Monitoring
 +Joint Commission on Accreditation of Healthcare Organizations
 +One Renaissance Boulevard
 +Oakbrook Terrace, IL 60181
 +Phone: (800) 994-6610
 +
 +STATE HMO REGULATORS
 +
 +In most states, the Department of Insurance monitors the activities of HMO's and will gladly take your complaints. California and Texas have specifically designed Departments'​ of Managed Care for this immediate purpose. These agencies frequently publish their statistics as they relate to the HMO complaints they have received. Please take the time to file your complaint. It is our hope that those HMO plans that are the least willing to accommodate patient concerns, be identified accordingly. File now:
 +
 +California Department of Managed Care: [[http://​www.insure.com/​articles/​statesinsurance/​ca/​|California]]
 +
 +Texas Department of Managed Care: [[http://​www.insure.com/​articles/​statesinsurance/​tx/​|Texas]]
 +
 +All 50 States Department of Insurance: [[http://​www.insure.com/​articles/​statesinsurance|Insur.com]]
 +
 +=====How to File a Health Insurance Complaint=====
 +
 +If you feel your health insurance company or agent has acted illegally or improperly there is a simple process to file a health insurance complaint:
 +
 +First and foremost, keep detailed records of all relevant documents. Write down all conversations you have had with your agent / company. Keep all written correspondences in one folder. Save copies of canceled checks, bank statements, or paystubs with payments to the health insurance company. Find and read through your policy agreement.
 +
 +Contact your health insurance company'​s customer service department. Explain your complaint and give them a reasonable amount of time to address the issue.
 +
 +If you still don't feel that the issue has been resolved, you can elevate the dispute:
 +
 +Consider your legal options. If the dollar amount in dispute is large, consider contacting an attorney to explain your problem and get their advice. Usually getting a referral from a friend is the best way to find an attorney. If this doesn'​t work, you can try using an online lawyer database. For smaller dollar amounts, you may want to file a small claims suit. The dollar limit for small claims are set on a state by state basis.
 +
 +Contact your state insurance commissioner. Almost all state commissioners have health insurance complaint forms on their websites (see State Insurance Sites for a list of state insurance departments). After filling out the form and submitting it, someone from your state will likely contact you to ask a few follow-up questions and may ask for supporting documents. Next, the state insurance department will contact your health insurance company to discuss the issue. Afterwards, they will either contact you to tell you that they are closing their investigation,​ or they will transfer you to a specialist in the insurance department to continue working on resolving the issue.
 +
 +Contact the Better Business Bureau and file a health insurance complaint with them as well. Health insurance companies work hard to resolve complaints because they hurt sales. Many people check with the BBB before buying insurance.
 +
 +If all fails, you still can warn others about the practices of your company/​agent:​
 +
 +Share your experience on consumer opinion websites such as epinions.com or consumeraffairs.com. I would name the health insurance company in the complaint, but not give the url of the health insurance website. Recent news articles have claimed that even links from complaint websites can help build web traffic to the referenced website.
 +
 +[[http://​www.ebuyingguides.com/​how/​health_insurance_c.htm|eBuyingGuide]]
 +
 +======External Links======
 +
 +=====Help Center=====
 +
 +Resources to Help You Find Coverage or Resolve an Insurance-Related Complaint
 +
 +[[http://​www.helpinsure.com/​help/​index.html}|HelpInsure.com]]
 +
 +=====Understanding the Difference Between HMO, PPO and POS=====
 +
 +[[http://​www.insurance.com/​health-insurance/​health-insurance-basics/​understanding-the-difference-between-hmo-ppo-and-pos.aspx|Insurance.com]]
 +
 +=====Stategies that May Help You Deal With Insurance Companies and HMOs=====
 +
 +[[http://​www.cherab.org/​information/​insurance/​Insurancestrategies.html|Cherab.org]]
 +
 +=====Insurance Complaints=====
 +
 +[[http://​insurance.freeadvice.com/​doi.php|FreeAdvice]]
 +
 +=====Would I need an insurance lawyer to handle my case?=====
 +
 +[[http://​law.freeadvice.com/​insurance_law/​health_insurance/​lawyer_handle_case.htm|AFreeAdvice.com]]
 +
 +=====State Insurance Information Links for all 50 states=====
 +
 +[[http://​www.insure.com/​articles/​statesinsurance|Insure.com]]
 +
 +=====How to File a Complaint Against an Insurance Company=====
 +
 +[[http://​www.ehow.com/​how_5010152_file-complaint-against-insurance-company.html|eHow]]
 +
 +=====Georgia Office of Insurance and Safety Fire Commissioner=====
 +
 +[[http://​www.gainsurance.org/​consumerservice/​Complaint.aspx|GAInsComm]]
 +
 +======See also:======
 +
 +[[http://​www.lymphedemapeople.com/​thesite/​lymphedema_insurance_billing_guidelines.htm|Lymphedema Insurance Billing Guidelines]]
 +
 +[[http://​www.lymphedemapeople.com/​thesite/​lymphedema_letter_of_medical_necessity.htm|Lymphedema Letter of Medical Necessity]]
 +
 +[[http://​www.lymphedemapeople.com/​thesite/​lymphedema_how_to_appeal_insurance_denials.htm|Lymphedema How to Appeal Insurance Denials]]
 +
 +[[http://​www.lymphedemapeople.com/​forum/​topic.asp?​TOPIC_ID=845|How to fight your insurance company]]
 +
 +[[http://​www.lymphedemapeople.com/​thesite/​lymphedema_advocacy_insurance_comm.htm|State Insurance Commissioners]]
 +
 +[[http://​www.lymphedemapeople.com/​thesite/​lymphedema_insurance_coverage_for_treatment.htm|Insurance Coverage for the Treatment of Lymphedema]]
 +
 +======Lymphedema People Resources======
 +
 +[[Lymphedema People Forums]]
 +
 +[[Lymphedema People Blogs]]
 +
 +[[Lymphedema People Glossaries]]
 +
 +[[Lymphedema People Online Support Groups]]
 +
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 +
 +  * [[Terms of Use]]
 +
 +  * [[Rules of Conduct]]
 +
 +  * Contact:
 +
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 +
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how_to_file_a_complaint_against_your_insurance_company.txt · Last modified: 2012/10/16 14:40 (external edit)