Helping You with Your Insurance Complaint

(February 2011)

Note: TDI uses the information you provide in a complaint form to help resolve your complaint. Resolution may require us to share the information with the person or company named in your complaint. Complaint information may also be released to the public on request through the Texas Public Information Act. Certain information, such as medical records, financial information, and e-mail addresses, may be considered confidential by state and federal law and not subject to release. Sharing this information to allow us to process your complaint does not waive these confidentiality protections.

The Texas Department of Insurance (TDI) helps consumers resolve more than 30,000 insurance-related complaints each year. Because of our efforts, consumers receive more than $35 million a year in additional claim payments and refunds. This publication explains how we can help you with your insurance problem and how you can file a complaint.

To file a complaint, visit our website.

How We Can Help

We review insurance, title, HMO, and workers’ compensation complaints involving:

claim and benefit disputes
false advertising
misrepresentation
suspected insurance fraud.

Your complaint may be against an insurance company, HMO, insurance agent, or adjuster.

We probably cannot resolve complaints against service providers – including body shops, building contractors, and doctors – unless the complaint involves the actions of insurers or HMOs. Complaints against service providers should be sent to the licensing or enforcement agency that regulates them.

Fully Funded and Self-Funded Health Benefit Plans

Fully funded plans are those in which the insurance company or HMO assumes the total risk for paying claims. Most health plans offered by small- and medium-sized employers are fully funded. TDI has jurisdiction over these plans and can help you resolve complaints against them.

However, many large employers have self-funded plans that are regulated by federal law and are under the jurisdiction of the U.S. Department of Labor. Employers with self-funded plans set aside money and employee contributions each month to pay health claims. A self-funded plan may hire an insurance company, HMO, or third-party administrator to work with providers and handle claims and paperwork, but the employer assumes the insurance risk.

Federal law prohibits states from regulating self-funded plan benefits or third-party administrators. Certain other group health plans maintained by governments, churches, some school districts, and out-of-state insurance organizations also are exempt from most state regulations, but may be regulated by local governments.

Here are some tips to help you avoid problems with your health plan and to get help if you need it:

Verify whether the plan is fully insured or self-funded. It might not be obvious.
Read your benefit booklet carefully. Understand what is and is not covered.
Follow all procedures and deadlines for getting medical treatment and filing claims, complaints, and appeals.
Take complaints and appeals to the person or office stated in your benefits booklet and other plan documents.
If the plan is fully insured, take any unresolved complaints to TDI.
If the plan is self-funded and offered by a private sector employer or bona fide union, take unresolved complaints to the Dallas office of the U.S. Department of Labor's Pension and Welfare Benefits Administration. The phone number is 972-850-4500.
If the plan is self-funded but offered through a government or church employer, follow the appeals procedures in your benefits booklet and other plan documents. In most cases, responsibility for resolving disputes rests with the governing body of the employer sponsoring the plan, such as a school board or county commissioners' court.

Before You File a Complaint

If you have a complaint, contact your company first. Many complaints can be resolved without our intervention by contacting the company and talking to them about your issue.

We require most insurance companies in Texas to have a toll-free telephone number for customer assistance. The toll-free number should be listed on your policy. You may also get the number by calling our Consumer Help Line or using the Check Companies feature on our website

1-800-252-3439
463-6515 in Austin
www.tdi.state.tx.us

When you call your company:

Have your policy number ready.
Ask for a written response to your complaint.
Follow up in writing. Describe your complaint and how you expect the company to resolve it.
Send copies (not originals) of letters, notes, invoices, canceled checks, advertising materials, or other documents that support your complaint.

Appraisal Process

Most automobile and homeowners policies allow you to resolve claim disputes through an appraisal process. You can use the appraisal to negotiate with the company, or to appeal or take the matter to court. Ask your company if your policy allows an appraisal.

In the appraisal process, you and the insurance company hire separate damage appraisers. The two appraisers choose a third appraiser to act as an umpire. The appraisers review your claim, and the umpire rules on any disagreements. You are required to pay for your appraiser and half of the umpire's costs.

You and the insurance company must accept the umpire’s decision about the loss amount. If there is a dispute over what is covered, you can ask the company to reconsider the coverage issue.

TDI’s Complaint Process

You may complain to us if you cannot resolve your dispute directly with your company and you haven't been through the appraisal process.

To file an insurance complaint online, visit our website. You may also e-mail, mail, or fax the complaint form, along with copies of your supporting documents, to

Texas Department of Insurance
Consumer Protection Program (MC 111-1A)
P.O. Box 149091
Austin, TX 78714-9091
Fax: 512-475-1771
E-mail: ConsumerProtection@tdi.state.tx.us

If you have a complaint against an HMO, mail or fax your complaint along with copies of your supporting documents to

Texas Department of Insurance
HMO Quality Assurance Section (MC 103-6A)
P.O. Box 149091
Austin, TX 78714-9091
Fax: 512-322-4260

If your dispute involves a workers’ compensation claim, call the Injured Worker Hot Line or your local Division of Workers' Compensation field office. The field office will tell you how you can schedule a benefit review conference to help resolve your dispute.

1-800-252-7031

We need the following information to investigate your complaint:

your name, address, and daytime telephone number
the exact name of the insurance company
the name of agents or adjusters involved
your policy number
your claim number and the date of your loss, if applicable
a copy of both sides of your insurance card
a description of your problem
what you believe would be a fair resolution of your complaint
copies of all supporting documentation, including invoices, canceled checks, advertising materials, and any letters between you and the company or agent.

After you send your complaint to us, we will:

Send you an acknowledgment letter with the name and phone number of the complaint specialist assigned to your complaint.
Notify the company about your complaint and ask for a detailed response.
Send you a copy of the company’s response and an explanation of the outcome, usually within 45 days after we receive your complaint.
Determine if your issue was handled appropriately and within the terms of the policy or certificate of coverage.
Determine if the company, agent, or adjuster broke state insurance laws, and take enforcement action when laws are broken.

While we make every effort to help you resolve your complaint, we cannot:

Make determinations about negligence or fault in an accident. These types of disputes must be resolved in court.
Resolve a dispute between you and the insurance company when the only evidence is your word.
Force a company to pay a disputed claim or make an exception to the contract if no insurance laws have been violated.
Give legal advice or make medical judgments.

Even if we can’t resolve your complaint, your complaints and inquiries help us identify issues and potential problems with insurance companies, HMOs, agents, or adjusters. Our involvement can also cause companies to look more closely at your concerns.

If you’re not satisfied with the results, you can discuss your concerns with an attorney. You may also request alternative dispute resolution (ADR) to settle problems with your insurance company. ADR uses techniques – such as mediation with a neutral third party – to settle disputes outside court.

Look in your telephone book for attorneys and mediation services. If you need help finding an attorney, call the State Bar of Texas Lawyer Referral Information Service

1-800-252-9690
www.texasbar.com

Be Claim Smart

Most of the complaints we deal with involve disputes over claim settlements. Follow these tips to help avoid claim settlement problems:

Read your policy carefully. A policy is a contract between you and the insurance company. Don't rely solely on your agent to tell you what your policy covers.
Read the Consumer Bill of Rights. Insurance companies must include it with personal automobile, homeowners, and credit life policies or renewals. It explains your rights and responsibilities. For a copy, call your insurance company or visit our website.
Keep copies of all documents and take notes about all calls between you and the insurance company. Include the date and subject of any conversations you have and the name and title of the person you spoke to.
Ask the company for the specific language in the policy related to your claim. Determine whether the disagreement is because you and the insurance company read your policy differently.

Auto and Homeowner Claim Tips

Keep all receipts for repairs you make after your property is damaged. Auto and homeowners policies may require you to make reasonable and necessary repairs to prevent further damage. Your policy covers the cost of these repairs. If possible, take photos or videos of the damage before making temporary repairs.
Don't make permanent repairs until the adjuster has inspected the damage. Keep the damaged property for the claims adjuster to inspect. Ask the adjuster for an itemized explanation of the claim settlement offer. For homeowners claims, this should include sales tax, depreciation, and holdback depreciation for policies with replacement cost coverage. Holdback depreciation is the money your company won’t pay until repairs are finished or the items are replaced. Ask the adjuster how they get this number.
Be prepared to negotiate to get a fair settlement. Don't be shy about to negotiating with the company for a better offer.

Accident and Health Claim Tips

Ask your doctor to provide your insurance company with details about your treatment, medical condition, and prognosis.
Consider the IRO process. If your company or health maintenance organization (HMO) refuses to pay for a recommended or ongoing treatment because it determined that the treatment was not medically necessary or appropriate, you can request binding review by an independent review organization (IRO). Independent reviews are available if Texas law requires your plan to participate or if the plan voluntarily participates in the IRO process. For more information, call TDI's IRO Information Line at 1-888-TDI-2IRO (834-2476) or 322-3400 in Austin.
Consider mediation. If you have health coverage through a preferred provide plan and have a dispute about an outstanding bill you received from an out-of-network hospital-based doctor, you may be able to resolve your dispute through mediation. If you choose mediation, your out-of-network hospital-based doctor and your plan will meet to discuss the outstanding bill. If the mediation is unsuccessful, you may have to resolve the dispute in court. Visit our website to learn more about the program and eligibility
www.tdi.state.tx.us/consumer/cpmmediation.html

Workers' Compensation Claim Tips

Workers' compensation is a state-regulated insurance program that pays your medical bills and a portion of your lost wages if you are injured at work or have a work-related illness. To get workers' compensation benefits, your employer must have workers’ compensation insurance or be self-insured. Texas employers are not required to have workers' compensation insurance.

If you have a work-related injury or illness, you must tell your employer within 30 days of the date you were injured or became ill, or within 30 days of the date you first knew your injury or illness might be work-related. Failure to notify your employer in a timely manner could cause you to lose your right to benefits.

You must also notify TDI's Division of Workers' Compensation (DWC) of your injury or illness within one year of the date you became injured or ill, or within one year of the date you knew your injury or illness might be work-related. Failure to notify DWC in a timely manner could cause you to lose the right to get benefits.

If you have a dispute about your workers' compensation claim, contact your local DWC field office. Workers' compensation claims disputes are handled through a formal administrative process. For more information, call the Injured Worker Hot Line

1-800-252-7031

Deadlines for Payment of a Claim

Texas law requires insurance companies to pay first-party claims promptly. A first-party claim is one you file against your insurance company. Texas' prompt-payment law requires licensed insurance companies to

Acknowledge claims, begin investigations, and request information within 15 days after receiving a claim. Surplus lines carriers have 30 days to complete this process. (A surplus lines carrier is an out-of-state company not licensed in Texas but eligible to insure hard-to-place risks.)
Notify you in writing of the acceptance or rejection of your claim within 15 business days after receiving all required information. This deadline may be extended an additional 15 days in the event of a declared weather-related or natural disaster.
If the company cannot accept or reject your claim within the time limit, the company must tell you why it needs more time. The company will then have up to 45 additional days after this notice to accept or reject your claim.
Give the reason in writing for rejecting your claim.
Make payment within five business days after notifying you that your claim will be paid. Surplus lines carriers must pay your claim within 20 business days after notifying you that it will be paid.
Prompt-payment laws do not apply to liability insurance claims against another person's insurance company or claims involving:
- self-funded health plans
- workers' compensation
- mortgage guaranty or title insurance
- fidelity, surety, or guaranty bonds
- marine insurance (other than inland marine).

How to Avoid Future Complaints

Homeowners, Renters, and Condo Insurance

Know what your policy covers and what the limits are. You may want more coverage for certain items than your policy provides. For an added premium, you can buy endorsements that increase coverage or provide coverage for items not on your base policy. Some of the most common endorsements add replacement cost coverage and increase coverage for jewelry, fine arts, camera equipment, and computer equipment.
If you operate a business from home, ask your agent or company what coverages you have and what coverages you may need.
Make sure your coverage fits your needs. Check the limits of your coverage, including contents coverage. Your current coverage may be too low to replace your personal property if you've made additions or new purchases or if the replacement cost has risen because of inflation. Also, some policies may only pay actual cash value for your dwelling and contents, instead of the replacement cost.
Review your deductibles to make sure they fit your current financial situation.
Keep records of improvements to your property.
Maintain an inventory of personal property including furnishings, clothing, and valuables. Videotape or photograph the inside and outside of your home. Keep these photos or tapes in a safe deposit box or in a location other than your home.
Homeowners policies do not cover damage by rising water. If you're concerned about the possibility of flooding, consider buying flood insurance. Remember that you don't have to live in a flood plain to suffer a flood loss. For more information about flood insurance coverage, call your insurance agent or company, or the National Flood Insurance Program administered by the Federal Emergency Management Agency (FEMA) at 1-800-427-4661 or visit them online at www.fema.gov.

Automobile Insurance

Know your policy's coverages and coverage limits.
Consider your needs. Check your auto policy to see if it includes rental car reimbursement or comprehensive coverage, also called other than collision coverage. Comprehensive coverage pays for theft and damage resulting from causes other than accidents, such as hail and flooding. Rental car coverage pays for a replacement car while yours is being repaired because of a covered loss. It may not be available if your automobile is a total loss.
Review your deductibles. Look at the comprehensive and collision deductibles to make sure they fit your current financial situation and the age of your care.
Keep records of improvements to your automobile.

Life, Accident, and Health Insurance

Read your benefit booklet to know which benefits are covered. Review your health policy or benefit plan to make sure it fits your health needs. Pay attention to restrictions, exclusions, policy limits, lifetime coverage maximums, and policy definitions.
Determine if your policy or benefit plan covers your medical needs. For example, know whether your policy covers things such as outpatient care or day surgery. Limited benefit policies cost less but probably will not provide the benefits or services you need to meet most health care expenses.
Read your life insurance or annuity annual statements. Be aware of economic changes that may affect your policy's value.
Obtain approval for hospital admissions or provider referrals, if required. Understand how and when you should notify the insurance company or HMO after being admitted to the hospital in an emergency.
If your policy is a preferred provider plan, be sure you understand the financial consequences of going to an out-of-network provider.
Ask if your policy allows the health care provider to bill you for charges not paid by your health care plan.

For More Information or Assistance

For answers to general insurance questions or for information on filing an insurance-related complaint, call the Consumer Help Line between 8 a.m. and 5 p.m., Central time, Monday-Friday, or visit our website

1-800-252-3439
463-6515 in Austin
www.tdi.state.tx.us

You can also visit HelpInsure.com to help you shop for automobile, homeowners, condo, and renters insurance, and TexasHealthOptions.com to learn more about health care coverage and your options.

For printed copies of consumer publications, call the 24-hour Publications Order Line

1-800-599-SHOP (7467)
305-7211 in Austin

Help us prevent insurance fraud. To report suspected fraud, call our toll-free Fraud Hot Line

1-888-327-8818

To report suspected arson or suspicious activity involving fires, call the State Fire Marshal’s 24-hour Arson Hot Line

1-877-4FIRE45 (434-7345)

For more information contact:

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