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You are here: www.tdi.texas.gov . pubs . consumer . cb003

Helping You with Your Insurance Complaint

(July 2014)

( En Español)

The Texas Department of Insurance helps consumers resolve complaints against insurance companies, health maintenance organizations (HMOs), insurance agents, and adjusters. Each year, we help more than 30,000 consumers get more than $35 million in additional claim payments and refunds.

To file a complaint, visit our website.

Note: To help you resolve your complaint, we must share the information you send to us with the person or company named in your complaint. Once your complaint is on file at TDI, it may be subject to release under the Texas Public Information Act to anyone who requests it. Certain information, such as medical records, financial information, and email addresses are generally confidential under state and federal law. Any information deemed confidential by law is not subject to release.

How We Can Help

TDI can help you resolve complaints about property, title, health, and workers' compensation insurance. Some of the common types of complaints we help resolve are

  • claim and benefit disputes
  • false advertising
  • misrepresentation
  • suspected insurance fraud.

We don't have jurisdiction over service providers - including body shops, building contractors, and doctors - so we won't be able to help you with complaints against them. Send complaints against service providers to the licensing or enforcement agency that regulates them.

Health Plan Complaints

TDI can help you with complaints against fully funded health plans. Fully funded plans are those in which the insurance company or HMO assumes the total risk for paying claims. Most health plans offered through small- and medium-sized employers are fully funded.

TDI doesn't handle complaints against self-funded plans. 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 set aside money and employee contributions each month to pay claims. They may hire an insurance company, HMO, or third-party administrator to handle claims and paperwork.

If you have a self-funded health plan through a government or church employer, follow the appeals procedures in your benefits booklet and other plan documents.

If the plan is self-funded and offered by a private sector employer or union, file a complaint with the Dallas office of the U.S. Department of Labor's Employee Benefits Security Administration

Dallas Regional Office
525 South Griffin St, Room 900
Dallas, Texas 75202

If you're not sure what type of plan you have, look at your plan documents or talk to your plan administrator. You will also find information about filing a complaint and using the dispute resolution process.

Before You File a Complaint

If you have a complaint, call your company first. Many complaints can be resolved by calling the company and talking to them about your issue.

Most insurance companies in Texas have toll-free telephone numbers for customer assistance. The toll-free number should be listed on your policy. You can also get the number by calling our Consumer Help Line at 1-800-252-3439 or using the Company Lookup feature on our website at www.tdi.texas.gov .

Do the following 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 want 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 auto and homeowners policies have an appraisal process for resolving disputes about the amount of damages your company will pay. You also have the right to appeal the company's decision or take the matter to court. Ask your company if your policy has an appraisal process.

Filing a Complaint

There are several ways to file a complaint:

  • Visit our website at www.tdi.texas.gov
  • Email us at ConsumerProtection@tdi.texas.gov
  • Send us a fax at 512-490-1007
  • Mail your complaint to
    Texas Department of Insurance
    Consumer Protection Section (MC 111-1A)
    P.O. Box 149091
    Austin, TX 78714-9091

If your dispute involves a workers' compensation claim, call the Injured Employee Hotline at 1-800-252-7031 or your local TDI Division of Workers' Compensation (DWC) field office. The field office will tell you how you can schedule a benefit review conference to help resolve your dispute.

Information We'll Need

We need the following information to investigate your complaint:

  • your name, address, and daytime phone 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
  • a copy of both sides of your insurance card, if appropriate
  • a description of your problem
  • what you believe would be a fair resolution of your complaint
  • copies of all supporting documents, including invoices, canceled checks, advertising materials, and any letters between you and the company or agent.

Processing your Complaint

After you send your complaint to us, we will

  • send you an acknowledgment letter.
  • tell 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.
  • decide if the company handled your issue appropriately and within the terms of the policy or certificate of coverage.
  • decide if the company, agent, or adjuster broke state insurance laws or administrative rules, and take enforcement action when laws or rules are broken.

While we make every effort to help you resolve your complaint, there are certain issues that we can't help you resolve. These include:

  • Determining who was negligent or at fault in an accident. You'll usually have to resolve these issues in court.
  • Resolving a dispute between you and the insurance company when the only evidence is your word.
  • Forcing a company to pay a disputed claim or make an exception to the policy if the company's refusal to pay the claim didn't violate any insurance laws or rules.
  • Giving legal advice or making medical judgments.

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

If You're not Satisfied

If you're not satisfied with the results, you may 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 at 1-800-252-9690 or visit the website at www.texasbar.com.

Be Claim Smart

Most of the complaints we deal with involve disputes about 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 or HMO. Don't rely on your agent to tell you what your policy covers.
  • Read the Consumer Bill of Rights. Insurance companies and HMOs must include it with personal auto, homeowners, and credit life policies or renewals. It explains your rights and responsibilities. For a copy, call your insurance company or visit our website at www.tdi.texas.gov/commish/rights.html.
  • Keep copies of all documents and take notes about all calls you have with the insurance company or HMO. Include the date and subject of any conversations you have and the name and title of the person you spoke to.
  • Keep a written record of all conversations you have with your company or agent. Follow up with an email or letter after any phone calls.
  • Ask the company to show you what language in the policy it's using to settle your claim. The disagreement might be because you and the insurance company or HMO read your policy differently.

Auto and Homeowner Claim Tips

  • Keep all receipts for repairs you make to your damaged property. 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 pictures 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 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 for a fair settlement. Don't be shy about negotiating with the company for a better offer.

Accident and Health Claim Tips

  • Ask your doctor to provide your insurance company or HMO with details about your treatment, medical condition, and prognosis.
  • Consider the IRO process. If your insurance company or 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 1-866-554-4926 or 512-322-4266 in Austin. You may also email URAGrp@tdi.texas.gov.
  • Consider mediation. If you have health coverage through a preferred provider 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.texas.gov/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 aren't 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 tell your employer in a timely manner could cause you to lose your right to benefits.

You must also tell DWC about 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, call your local DWC field office. Workers' compensation claims disputes are handled through a formal administrative process. For more information, call the Injured Employee Hotline at 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. Licensed insurance companies must

  • Begin investigating and requesting 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 that isn't licensed in Texas but is allowed to insure risks that companies in the standard market aren't willing to insure.)
  • Accept or reject your claim in writing within 15 business days after receiving all required information. This deadline may be extended another 15 days in the event of a declared weather-related or natural disaster.
    Note: If the company can't accept or reject your claim within the time limit, it must tell you why it needs more time. The company will have up to 45 additional days after this notice to accept or reject your claim.
  • Tell you in writing its reason for rejecting your claim.
  • Pay you within five business days after telling you that it will pay your claim. Surplus lines carriers must pay your claim within 20 business days after telling you that it will pay you.

Prompt-payment laws don't apply to liability insurance claims against another person's insurance company (called third-party claims) 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 than your policy provides. For a higher 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, art, 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 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.
    Note: Replacement cost is what you would pay to rebuild or repair your home, based on current construction costs. Actual cash value is the replacement cost of your property minus depreciation.
  • Review your deductibles to make sure they fit your current financial situation. Higher deductibles will lower your premium, but you'll have to pay more out of your own pocket if you have a claim.
  • Keep records of improvements to your property.
  • Keep a home inventory of personal property including furniture, clothes, and valuables. Record or photograph the inside and outside of your home. Keep the pictures and recordings in a safe deposit box or somewhere other than your house (like your office or a family member's house).
  • Homeowners policies don't cover damage by rising water. If you're concerned about the possibility of flooding, think about 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.

Auto 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 car 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 car.
  • Keep records of improvements to your car.

Life, Accident, and Health Insurance

  • Ask if your health plan is fully funded or self-funded. It might not be obvious.
  • 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.
  • 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.

For More Information or Assistance

For answers to general insurance questions, for information about filing an insurance-related complaint, or to report suspected insurance fraud, call the Consumer Help Line at 1-800-252-3439 between 8 a.m. and 5 p.m., Central time, Monday-Friday, or visit our website at www.tdi.texas.gov.

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 at 1-800-599-SHOP (7467).

To report suspected arson or suspicious activity involving fires, call the State Fire Marshal's 24-hour Arson Hotline at 1-877-4FIRE45 (434-7345).

The information in this publication is current as of the revision date. Changes in laws and agency administrative rules made after the revision date may affect the content. View current information on our website. TDI distributes this publication for educational purposes only. This publication is not an endorsement by TDI of any service, product, or company.

For more information contact:

Last updated: 11/21/2014

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Translation by WorldLingo