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How to File a Complaint Against Your Insurance Company

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How to File a Complaint Against Your Insurance Company

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Pat O'Connor

Lymphedema People / Advocates for Lymphedema

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After we have submitted an appeal, failed in mediation and exhausted all attempts of resolving a problem with our health insurance company, our final option before anctually hiring an attorney is to file a formal complaint against the company with your state insurance commissioner.

This section will provide information on how to do that as well s provide additional links for further assistance.

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See also:

Lymphedema and Insurance Companies

http://www.lymphedemapeople.com/thesite/lymphedema_and_insurance_companies.htm

Lymphedema How to Appeal Insurance Denials

http://www.lymphedemapeople.com/thesite/lymphedema_how_to_appeal_insurance_denials.htm

Lymphedema Advocacy - State Insurance Commissioners

http://www.lymphedemapeople.com/thesite/lymphedema_advocacy_insurance_comm.htm

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For State by State information on filing an complaint with the insurance commissioner - type in How to file an Insurance Complaint - in your browser then scroll until you find your state

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Filing a Complaint With Your State Insurance Commissioner

From Bobbie Sage

State insurance commissioners resolve thousands of complaints every year. Complaints vary from disputes with insurance companies about how one's claim was handled to problems with the sale and service of an insurance policy. If you feel your insurance company has not been fair with your claim or policy, you have the right to file a complaint with your state insurance commissioner.

If you decide you need to file a complaint, there are a few things you will want to do or be prepared to do. First, go to your state insurance commissioner's web site and find out what the processs is to file a complaint. Many state insurance commissioners will have a complaint form available to download or fill out online. Once you know how to start the process, you will want to compile every piece of documentation that pertains to the complaint and start keeping records of all phone conversatins and agent contacts. Most all insurance companies have large claims departments and service call centers where you will almost always speak to a new person each time you contact the company, so it is important for you to keep your own records of all conversaions with the insurance company. Once you have your documents together and know how to file the complaint, it is now time to officially file it.

Now that the complaint is filed, your state insurance commissioner's office will likely contact you asking for any additional documentation they will need. In most cases the next step the commissioner will take is to send a copy of the complaint to the insurance company and give them a designated response time. Most likely, if the commissioner feels the response is adequate, they will send you a copy of the explanatory letter. But, if the commissioner feels the response from the company is not adequate, your case will probably be taken over by a state designated person that will work with you and the company to resolve the issue and to find out if any laws were broken.

One important thing to remember in the complaint process is that even if your case is assigned a state designated person to try to resolve the situation, that person cannot act as your attorney. Depending on what is at stake due to the complaint and your confidence in dealing with the insurance company, hiring an attorney to represent you should always be a consideration.

Important disclaimer information about this About site.

http://personalinsure.about.com/cs/whattoexpect/a/aa031604a.htm

Special Thanks to Tina for sending this in

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How to file a complaint with the Insurance Division 

http://newyork.cbslocal.com/2011/08/29/after-irene-tips-for-filing-an-insurance-claim-and-making-repairs/

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Sample Complaint to State Insurance Commission

TODAYíS DATE

NAME OF STATE INSURANCE COMMISSION STREET ADDRESS CITY, STATE ZIP CODE

Dear Insurance Commissioner:

I have filed the attached insurance claim with NAME OF INSURANCE COMPANY on DATE OF CLAIM. My physician has deemed this therapy medically necessary for my specific condition, but my insurance company has denied me access to the standard of care. I have had the following specific problem(s) with this insurance company:

1) EXAMPLE: NAME OF INSURANCE CO. has refused to cover my physician prescribed, medically necessary therapy.
2) EXAMPLE: My claim has been neither paid nor denied.
3) EXAMPLE: NAME OF INSURANCE CO. has not acknowledged my request for a copy of their policy regarding the therapy my physician has prescribed for me.
4) EXAMPLE: In violation of my policy, NAME OF INSURANCE CO. has denied my claim.

Please accept this letter as a formal written complaint against NAME OF INSURANCE COMPANY.

Sincerely,

PATIENT NAME
PATIENT ADDRESS
CITY, STATE ZIP CODE
PHONE #

CC: MEDICAL DIRECTOR, NAME OF INSURANCE COMPANY
NAME OF PATIENTíS PHYSICIAN
National Psoriasis Foundation

Enclosures: Insurance Claim
ANY OTHER RELEVANT DOCUMENTS (FOR EXAMPLE: LETTER FROM PHYSICIAN, ETC)

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How to file a complaint against your insurance company - HMO

FILE AN HMO COMPLAINT

Oversight is growing in the HMO marketplace. Should you have a complaint about an HMO practice... report it. We have listed below agencies in each of the 50 states along with a nation HMO accreditation review board. In a growing number of states, HMO complaints are being tallied and are often made public. Employer groups closely evaluate these complaints when determining which HMO contracts to accept each year. You can impact which HMO's will continue practicing in your area. Empowered patients make their voices heard, if you have to resolve your issue are still unhappy with your HMO treatment... file a complaint:

The Joint Commission on Acceditation of Healthcare Organizations (JCAHO) wants to know about your complaint. Send the complaint by e-mail, Fax or mail and include the name, street address, city and state of the health care organization.

E-Mail: complaint@jcaho.org

Fax: Office of Quality Monitoring
(630) 792-5636

Mail: Office of Quality Monitoring
Joint Commission on Accreditation of Healthcare Organizations
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
Phone: (800) 994-6610


STATE HMO REGULATORS

In most states, the Department of Insurance monitors the activities of HMO's and will gladly take your complaints. California and Texas have specifically designed Departments' of Managed Care for this immediate purpose. These agencies frequently publish their statistics as they relate to the HMO complaints they have received. Please take the time to file your complaint. It is our hope that those HMO plans that are the least willing to accommodate patient concerns, be identified accordingly. File now:

California Department of Managed Care: www.opa.ca.gov

Texas Department of Managed Care: www.ers.state.tx.us

All 50 States Department of Insurance: www.insure.com/links/doi.html

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Helping You With Your Insurance Complaint (example covering TEXAS)

http://www.tdi.texas.gov/pubs/consumer/cb003.html

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Strategies for Dealing with Health Insurance Companies and HMOs

http://www.noonansyndrome.org/articlesinfo/insurance1.html

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COMPLAINT TO DEPARTMENT OF INSURANCE

http://law.freeadvice.com/insurance_law/insurance_law/insurance_department.htm

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Coventry tops complaint list for HMOs

http://www2.ljworld.com/news/2004/aug/01/coventry_tops_complaint/

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WOULD I NEED A LAWYER TO HANDLE MY CASE?

http://law.freeadvice.com/insurance_law/health_insurance/lawyer_handle_case.htm

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See Also

LYMPHEDEMA INSURANCE BILLING GUIDELINES

http://www.lymphedemapeople.com/thesite/lymphedema_insurance_billing_guidelines.htm

Lymphedema Letter of Medical Necessity

http://www.lymphedemapeople.com/thesite/lymphedema_letter_of_medical_necessity.htm

Lymphedema How to Appeal Insurance Denials

http://www.lymphedemapeople.com/thesite/lymphedema_how_to_appeal_insurance_denials.htm

How to fight your insurance company

http://www.lymphedemapeople.com/forum/topic.asp?TOPIC_ID=845

State Insurance Commissioners

http://www.lymphedemapeople.com/thesite/lymphedema_advocacy_insurance_comm.htm

Insurance Coverage for the Treatment of Lymphedema

http://www.lymphedemapeople.com/thesite/lymphedema_insurance_coverage_for_treatment.htm

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Join us as we work for lymphedema patients everywehere:

Advocates for Lymphedema

Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.

http://health.groups.yahoo.com/group/AdvocatesforLymphedema/

Subscribe:AdvocatesforLymphedema-subscribe@yahoogroups.com

Pat O'Connor

Lymphedema People / Advocates for Lymphedema

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Updated Dec. 28, 2011