Having issues with your policy or your health insurance company's interpretation? Then you need to file a complaint. But the question is, how?
Reading this article, you will learn about why some people file complaints against their health insurance providers. You will also discover the step-by-step process of filing a claim and their corresponding next steps. You will also learn about the roles of an ombudsman and the state insurance regulator.
To file a complaint, there are several escalating steps. The process begins with contacting your insurance agent, then speaking to an executive in the company. The process can be further escalated by contacting outside sources such as an ombudsman, the state insurance regulator, an arbitrator, and a lawyer.
This article contains information collated from high-quality sources, including Healthcare.gov, insurance advocacy groups, and various Department of Insurance resource sites. This is done to ensure the content therein is trustworthy, reliable, and accurate at the time of writing.
Why You Might Want To File A Complaint
Most times, your interaction and agreement with your health insurance company go off without a hitch. However, there are times when you will have one complaint or another about your insurer. It could be that your claim was rejected for one reason or another.
It could also be that your health insurance company refused to comply with the law or honor its end of the policy contract.
When you have to file a complaint against a health insurance company, you can be faced with a lot of choices. You could choose to appeal to a representative at your health insurance provider, complain to the insurance commissioner in your state. You could also choose to hire a lawyer.
If you are sure you want to file a complaint against your health insurance company, the following are the most widespread choices:
- Speak to an agent or representative at your insurer
- Appeal to someone on the executive team at your health insurance company
- Request that a third party like an insurance ombudsman mediate the dispute
- Seek arbitration if your health insurance policy allows it
- File a complaint against your health insurance company with your state's department of insurance
Regardless of the option you choose, you have to ensure that you have ready a timeline of your claim, the departments involved, copies of bills, and any individuals you have spoken to up to that point.
Contact Your Insurance Agent
If you purchased your health insurance plan via an insurance agent, that individual could act as an advocate, assisting you with your policy complaint.
If your complaint has to deal with you not getting reimbursed or any insurance-related issue, your first port of call should always be your insurance agent. This is because an insurance agent's interest lies with you and not the health insurance company.
An insurance agent can be an excellent ally to have, and they're the most effortless method your complaint can reach a good resolution. If speaking with an agent does not prove effective, you can move on to the agent's supervisor. This should be the next step in your complaints process.
If an insurance agent can not assist you, there is always a supervisor you can request to help. This, in most situations, is where complaints get resolved.
Speak With Someone On The Executive Team
The next step would be to have a word with your health insurance provider. Every insurance company has its own process that its policyholders can follow before they request outside help.
Your health insurance provider might choose not to provide information on its appeals process. Still, you can request the information and ensure you do so before complaining to an outside entity.
Some health insurance providers hide this information deep in their packages or website. You have to take the time to find out what your health insurance provider's process is.
Some health insurance providers require that all appeals are submitted in writing. The appeal should have your name, as it is on your policy, your health policy ID number, the date, service provider, and a reference number, also known as a claim number.
Some health insurance providers also place deadlines on their appeals timeline. For instance, Blue Cross Blue Shield requires you to file the appeal within three months of the first notification of your benefits denial.
Contact An Ombudsman
This complaint avenue is open to states that have ombudsman services in their department of insurance. An ombudsman is a department advocate who has been officially designed to not only protect your interest but investigate any complaints you may have.
It is their job to protect you, the policyholder, standing as a watchdog to ensure any emerging issues are taken care of. If you are unable to make any progress with the insurance agent or the health insurance manager proves unhelpful, you can contact an ombudsman as your next step.
Certain states have different action plans for their ombudsman service, with New Jersey's helping consumers with things such as coverage questions, claims processing, insurance availability, and any other matters that pertain to health insurance assistance and consumer education.
On the other hand, California has an ombudsman service that has been tasked with making sure the state's Department of Insurance offers the highest quality of customer service to its public officials, brokers, agents, insurers, and customers.
Should your ombudsman approach not provide your expected result, you could consider making your complaint public. Using social media to highlight your problem could create a stir that grabs the attention of your health insurance provider.
Doing this enables other customers to know exactly how that health insurance provider handles issues. This can help them make an informed decision when next they want to purchase health insurance.
Filling A Complaint With Your State Insurance Regulators
The McCarran-Ferguson Act of 1945 means that insurance companies operating within the US are exempt from most federal regulations. You can check with the NAIC or National Association of Insurance Commissioners' site to find the right insurance contact for your state.
While not regulatory, the Affordable Care Act requires health insurance policies, and by extension, the provider offers ACA-compliant plans. If the source of your complaint is a non-ACA-compliant plan, you can address your complaint via the Healthcare.gov site.
Additionally, you could take your complaints to the department of insurance in your state as they are the ACA-mandated complaint takers. It is their role to start an investigation into the matter.
You should note that your health insurance provider will be expected to clarify their view just as you do. Once adjudication has been completed, the body can close the complaint, certifying that no insurance legislation was broken.
If insurance-related legislation was broken, the body would refer the case to its corresponding enforcement division.
You should note that complaining to a state's department of insurance isn't going to always result in favorable proceedings. For example, in Ohio, the insurance department states that it cannot force a health insurance company to resolve your claim if it deems that no laws were broken.
The same also goes for if you think the insurance agent or provider has been unfair to you. You can find out just how many complaints your state's insurance department has received as they are public records.
Here you can find out how many people purchased a plan, the value of the policies and how many complaints they had. The insurance department creates a complaint ratio, which is the number of complaints divided by the number of written policies.
When a health insurance company has a higher complaint ratio, it means its performance is bad.
This option is available for individuals that have been officially denied coverage. Your health insurance company may offer arbitration as a way to agree on the next step. Most health insurance providers are now choosing arbitration. However, you cannot go down this route if your policy doesn't implicitly state it.
If there isn't any information concerning arbitration, you might need to move to litigation.
There are two forms of arbitration; non binding and binding.
Health insurance providers that have arbitration on their policies typically mandate binding ones. Non Binding arbitration means that you or your health insurance provider can oppose the arbitrator's judgment by filing a lawsuit.
Enlisting The Services Of A Lawyer
There are times when you require professional assistance, someone that has experience in dealing with insurers. This is when a lawyer comes in. A lawyer can be useful if your claim is complicated, expensive, or even large.
You should not wait until it seems like there is no hope for your claim. It is always better to hire a lawyer earlier in your complaint process instead of waiting around.
Sometimes a simple conversation with a representative at your insurance company can yield the result you want. It could also be that your respite came from speaking to someone on the management team.
Since they have more power, they can better interpret the policy rules and apologize for any failure on their part.
If your complaint process against your health insurance company doesn't go well or is cumbersome, you could ask your state via an advocacy group to streamline the policyholder complaints process.