Helping You with Your Insurance Complaint

(Revised March 2006)

Note: TDI uses the information disclosed in a complaint form to help resolve your complaint. Resolution may require TDI to share the information with the person or company named in your complaint. In addition, complaint information may also be released to the public upon request through the Texas Public Information Act. However, certain information, such as medical records, financial information, and e-mail addresses, may be confidential by state and federal law or the doctrine of common law privacy. Sharing this information for purposes of processing your complaint does not waive these confidentiality protections.

Introduction

Each year the Texas Department of Insurance (TDI) assists consumers with more than 30,000 insurance-related complaints. Because of TDI's efforts, consumers receive more than $30 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 consumer complaint.

Be 'Claim Smart'

Most complaints come from people unhappy 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. Don't rely solely on your agent to determine what your policy covers.
• Read the Consumer Bill of Rights. Insurance companies must include the "Consumer Bill of Rights" 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 the Office of Public Insurance Counsel website

  www.opic.state.tx.us.

• Keep copies of all correspondence between you and the insurance company. Write down information about your telephone and in-person contacts. Include the date, the name and title of the person you spoke with, and what was said.
• 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 interpret your policy differently.
• Be prepared to negotiate to get a fair settlement.
• Don't rush into making a settlement.

Auto and Homeowner Claims

• Auto and homeowners policies may require you to make reasonable and necessary repairs to protect your property from further damage. Your policy covers the cost of these repairs, so keep all receipts. Keep the damaged property for the claims adjuster to inspect. 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.
• Ask the adjuster for an itemized explanation of the claim settlement offer. For homeowners claims, this should include depreciation, holdback depreciation, and sales tax. Holdback depreciation is an amount of money withheld from your claim settlement until repairs are finished or the items are replaced. Ask how the adjuster determined the estimate amount.

Accident and Health Claims

• Ask your physician to provide your insurance company with details about your treatment, medical condition, and prognosis.
• If your health insurer or health maintenance organization (HMO) refuses to pay for a treatment because the insurer or HMO determined that the treatment was not medically necessary or appropriate, you can request binding review by an Independent Review Organization (IRO). For more information, call TDI’s IRO Information Line

  1-888-TDI-2IRO (834-2476).
  322-3400 in Austin

Workers’ Compensation Claims

Workers’ compensation is a state-regulated insurance program that pays your medical bills and replaces a portion of your lost wages if you are injured at work or have a work-related illness and. To receive workers’ compensation benefits, your employer must have worker’s compensation insurance or self-insurance as defined by the Texas Workers’ Compensation Act.

• If you suffer 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 get 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 or to reach your local DWC field office, 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 filed by you against your insurance company or HMO. Prompt-payment laws do not apply to liability insurance claims against another person's insurance company. They also do not apply to claims involving self-funded health plans; workers’ compensation; mortgage guaranty or title insurance; fidelity, surety, or guaranty bonds; or marine insurance (other than inland marine).

Texas' prompt-payment law requires licensed insurance companies and HMOs to

• Acknowledge claims, begin investigations, and request any needed 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 allowed 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 to process your claim. 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.

If You Have a Claim Dispute, Contact Your Company

Most insurance companies in Texas are required to have toll-free telephone lines for customer assistance. The toll-free number should be listed on your policy, or you can get the number by calling TDI's Consumer Help Line or using the "Insurer Search" feature on our website

1-800-252-3439
www.tdi.state.tx.us

Have your policy number ready when you call the company.

If you have a dispute with your agent or company, put it in writing. This encourages a written response. State your complaint and how you expect the company to resolve it.

Include with the complaint copies (not originals) of letters, notes, invoices, canceled checks, advertising materials, or other documents that support your complaint.

Many property and liability policies, such as automobile and homeowners policies, provide an "appraisal" process to resolve claim disputes. In this process, you and the insurance company hire separate damage appraisers. The two appraisers choose a third appraiser to act as an "umpire." The appraisers then review your claim, and the umpire rules on any disagreements. The umpire's decision is binding on you and the insurance company, but only for the loss amount. If there is a dispute over what is covered, you can still pursue a settlement of the coverage issue after the appraisal takes place. You are required to pay for your appraiser and half of the umpire's costs.

Next, Contact the Texas Department of Insurance

If you cannot resolve your dispute directly with your company, you may file a complaint with TDI. To file a complaint online, visit our website

www.tdi.state.tx.us

You may also e-mail, mail or fax your complaint 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

To help ensure that TDI receives all necessary information to investigate your complaint, include the following information with your complaint:

• your name, address and daytime telephone number
• the exact name of the insurance company
• the full name of any agent or adjuster who may be 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 concise 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.

If your dispute involves a workers’ compensation claim, call the Injured Worker Hot Line or contact your local Division of Workers’ Compensation field office

1-800-252-7031

What Complaints Are Accepted?

TDI accepts and reviews complaints against insurance companies, HMOs, insurance agents, adjusters, and fully insured or fully funded health benefit plans (health plans purchased by an employer from an insurance company or HMO are called fully insured or fully funded health benefit plans). The types of complaints reviewed include disputes about claims and benefits, false advertising, misrepresentation, and suspected insurance fraud.

TDI probably cannot resolve complaints against service providers – including body shops, building contractors, and doctors – unless the complaints involve the actions of insurers or HMOs. Complaints against service providers should be directed to the appropriate licensing or enforcement agency.

TDI may not be able to resolve your complaint, but our involvement typically causes insurers to look more thoroughly at your concern. In addition, your complaints and inquiries help us to assist other Texans by identifying issues of concern and may help identify potential problems with insurance companies, HMOs, or agents.

Important! Many employers have self-funded health benefit plans that are regulated by federal law. This means your employer may set aside funds and employee contributions each month to pay health coverage claims submitted by plan participants. A self-funded plan may hire an insurance company, HMO, or third-party administrator to coordinate providers and handle claims and paperwork, but the employer assumes the insurance risk. Federal law prohibits states from regulating benefits provided under valid self-funded plans or the third-party administrators that administer those plans. These plans come under the jurisdiction of the U.S. Department of Labor. 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.

To limit potential problems, especially with a valid self-funded plan, you should

• 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 seeking medical treatment and filing claims, complaints, and appeals.
• Take complaints and appeals to the person or office authorized 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

  214-767-6831

• 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, ultimate responsibility for resolving disputes rests with the governing body of the employer sponsoring the plan, such as a school board or county commissioners' court.

What Happens after You File a Complaint with TDI?

• You will receive an acknowledgment letter.
• TDI will notify the company of your complaint and ask for a detailed response. We will send you a copy of the company’s response.
• TDI will send you an explanation of the final outcome, usually within 45 days after we receive your complaint.
• If your complaint involves your workers’ compensation claim, you must contact your local DWC field office or call the Injured Worker Hot Line. You will be given information on how to schedule a benefit review conference to help resolve your dispute.

What Happens if You Are Not Satisfied with TDI's Results?

You may wish to consult an attorney to discuss your concerns. You may also request alternative dispute resolution (ADR) to settle disputes with your insurance company. ADR uses techniques such as mediation with a neutral third party to help settle a dispute outside a formal court of law.

Please consult your telephone book for listings for attorneys and mediation services. If you need help finding an attorney, call the Texas Lawyer Referral Service or visit the State Bar of Texas website

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

How to Avoid Future Complaints

Homeowners Insurance

• Know what your policy covers and what your policy’s limits are. You may want more coverage for certain items than your policy provides. For an added premium, you can buy "endorsements." Endorsements are policy amendments that cover items not on your base policy or increase the amount of coverage you have. Some of the most common endorsements increase coverage for jewelry, fine arts, camera equipment, coin or stamp collections, computer equipment, and radio and television satellite dishes and antennas.
• If you have a business in your home, you should check with your agent or company regarding what coverage you may or may not have.
• Be fully insured. Check the limits of your homeowners or renters coverage, including contents coverage. Your current coverage may be too low to replace your 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.
• 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, contact your insurance agent or company, or call the National Flood Insurance Program or visit the Federal Emergency Management Agency website

  1-800-427-4661
  www.fema.gov

• Keep records of improvements to your property.
• Make an itemized list 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.

Automobile Insurance

• Check your auto policy to see if it includes comprehensive coverage or rental car reimbursement. Comprehensive coverage is also called "other than collision" coverage. It pays for theft and damage resulting from causes other than accidents, such as hail and flooding. Rental car coverage pays if your auto is being repaired because of a covered loss. It may not be available if your automobile is a total loss.
• Review your comprehensive and collision deductibles to make sure they fit your current financial situation.
• Keep records of improvements to your automobile.

Life, Accident & Health Insurance

• Read your life insurance or annuity annual statements. Be aware of economic changes that may affect your policy's value.
• 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.
• Obtain precertification for hospital admissions or provider referrals, if required.
• Understand your responsibility to notify the insurance company or HMO after being admitted to the hospital in an emergency.
• If your policy is with a preferred provider plan, be sure you understand the consequences of going to an out-of-network provider.
• Determine 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, visit our website or call the Consumer Help Line between 8 a.m. and 5 p.m., Central time, Monday-Friday

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

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 Hotline

1-888-327-8818

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

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: ConsumerProtection@tdi.state.tx.us