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If you have a complaint about your health insurance company, there are a few ways to file a complaint. You can file a complaint with your state’s insurance department or with the federal government.
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Introduction
If you have a problem with your health insurance company, there are several things you can do to try to resolve the issue. Many times, simply contacting the customer service department of your insurance company can result in a resolution. If you’re not satisfied with the response or if you feel like your issue has not been resolved, there are other steps you can take, such as filing a complaint with your state’s insurance commissioner or taking your case to small claims court.
What is a Health Insurance Company?
A health insurance company is a company that contracts with medical providers to provide health insurance to its members. The company is responsible for paying the medical providers for the care its members receive. The members pay the company a monthly premium, and the company also pays a portion of the cost of care. When you have a health insurance policy, you are usually required to use in-network providers, which are providers that have a contract with your health insurance company.
What is a Complaint?
A complaint is defined as “any expression of dissatisfaction with any aspect of the quality of care or service you have received from your health insurer, HMO, or plan.” Complaints can be about any number of things, including:
-Billing
-Coverage
-Claims processing
-Customer service
– Denials of coverage or benefits
-Network participation
You can make a complaint by telephone, mail, or in person.
Who Can File a Complaint?
You can file a complaint if you’re a consumer or patient who believes you’ve been harmed by a health insurance company’s practices. You don’t need to be a U.S. citizen to file a complaint.
You can also file a complaint on behalf of someone else, but you may need that person’s permission. To give someone else permission to file a complaint for them, they must complete and sign this form: Authorization to Release Protected Health Information for Grievance or Complaint Resolution.
If you have any questions about whether you or someone else can file a complaint, please call us at 1-877-267-2323 (toll free) or TTY 1-866-226-1819, Monday – Friday, 8 a.m. – 8 p.m. ET.
How to File a Complaint
If you’re unhappy with the service you’ve received from your health insurance company, you have the right to file a complaint. Here’s how:
1. Gather your documents. You’ll need to have your insurance policy, any correspondence you’ve had with the company, and details of the issue you’re complaint about.
2. Contact your state’s Department of Insurance. Every state has an agency that regulates health insurance companies. You can find contact information for your state’s department on its website.
3. Explain your situation. Be clear and concise about what happened and why you’re dissatisfied. The Department of Insurance will likely ask for copies of your documentation, so have it handy.
4. Follow up. Once you’ve filed a complaint, be sure to follow up with the Department of Insurance to make sure it is being addressed. You should also keep copies of all correspondence in case you need to escalate your complaint.
What Happens After a Complaint is Filed?
Once you have filed a complaint with your state’s insurance department, an investigator will review your case and decide whether or not to pursue it. If the investigator believes that there is enough evidence to support your claim, he or she will contact the insurance company in question and attempt to resolve the issue. If the investigator is unsuccessful in resolving the issue, he or she may take legal action against the company.
What if the Problem is Not Resolved?
If your problem is not resolved, or if you are not satisfied with the response from the health insurance company, you have the right to file a formal complaint. This is also called an appeal.
To file a formal complaint, contact your state’s insurance department. You can find contact information for your state’s insurance department on the National Association of Insurance Commissioners (NAIC) website or by calling the NAIC Consumer Hotline at 1-855-408-1212.
When you contact your state’s insurance department, be sure to have the following information ready:
-Your name, address, phone number and email address
-The name of the health insurance company and your policy number
-A detailed description of the problem and what you have done so far to try to resolve it
-The dates of any events related to the problem
-The names and phone numbers of anyone who can help confirm what happened
Tips for Filing a Complaint
If you have a problem with your health insurance company, there are several things you can do to file a complaint.
First, try to resolve the issue directly with your insurer. If you are not able to do so, you can contact your state’s insurance department.
When you contact your state’s insurance department, be sure to have the following information ready:
-Your name, address and phone number
-The name of your health insurance company
-Your policy number
-A detailed description of your problem
-The dates of any relevant events (e.g., the date you contacted the insurer, the date of a denied claim, etc.)
-Any documents that may be helpful in resolving your complaint (e.g., correspondence from the insurer, denial notices, etc.)
Sample Complaint Letters
health insurance company.
Here are some sample complaint letters to use as a starting point when you’re writing your own letter. Remember, the goal is to be clear and concise, so don’t get too wordy. You’ll likely need to include some supporting documentation, so make sure to keep that handy.
Sample Complaint Letter 1
[Your Name]
[Your Address]
[Your City, State, Zip Code]
[Your Account Number]
[The Date]
[Name of the Company]
[Address of the Company]
[City, State, Zip Code of the Company]
Dear [Name of Contact Person],
I am writing to complain about the poor service I have received from your company. On [date], I contacted your customer service department and was told that my insurance policy did not cover the cost of my prescription medication. I was very surprised by this because I had been told by my agent that my policy did cover prescription costs. When I asked to speak to a supervisor, I was told that none were available and that I would have to call back another time. This is unacceptable. I need to speak to someone about this right away. Please call me at [your phone number] as soon as possible so we can resolve this matter.
Sincerely,
[Your Name]
Sample Complaint Letter 2
[Your Name]
[Your Address]
[Your City, State, Zip Code_]Return Reason Code_Vendor Invoice or Packing Slip_Medical Bill_Hospital Statement_Patient Statement_Other Patient Account Documentation (Please explain) Date Submitted: __/__/__
To Whom It May Concern:
I am writing because I am dissatisfied with the health insurance coverage I have been receiving from your company. In particular, I have been very unhappy with the way that my claims have been processed. On several occasions now, I have had claims denied that should have been covered, and it has been very difficult and time-consuming to get them resolved. This is causing me a great deal of financial hardship and stress, and I would like for it to stop immediately.
I am enclosing copies of documentation for three recent claims that were denied in error: [list claims here]. As you can see, these should all have been covered under my policy. I would like for you to process these claims immediately and issue refunds for any out-of-pocket expenses I have incurred as a result of your errors. In addition, I would appreciate an explanation for why these errors occurred and what steps you are taking to prevent them from happening in the future.
I am very disappointed in the level of service I have received from your company thus far, and unless these issues are resolved quickly and satisfactory, I will be forced to seek coverage elsewhere. Please contact me at your earliest convenience so we can discuss this matter further and come up with a resolution that works for both of us. Thank you for your time and attention in this matter._ __(Patient’s Signature)___ Date___(Patient’s printed name)____
Resources
If you have a problem with your health insurance company, there are several things you can do to file a complaint.
The first step is to contact the company directly and explain the problem. If you don’t get a satisfactory response, you can file a complaint with your state’s insurance commissioner. You can also file a complaint with the federal government’s Consumer Financial Protection Bureau if the problem is related to billing or payments.
If you need help filing a complaint, there are many resources available, including the National Association of Insurance Commissioners and the Consumer Financial Protection Bureau.
