Insurance Complaints
The most common problem involving health insurance is that consumers are finding that their insurance will not cover all the medical expenses that seem to be covered in their policies. Many consumers call the hotline about this concern because they are unsure where to turn.
You can appeal any decision made by your insurance company if you feel you have been treated unfairly. The steps to follow are listed below. Before you start your appeal, there are certain steps you should always follow:
1. Gather all your materials together.
2. Specifically define your problem so that you have confidence in relating you problem to others.
3. Specifically define exactly what you hope to achieve, that is, what are your goals.
4. Figure out the various options for action you have and then weigh these options carefully to decide what is best for you.
5. Follow through with any action you begin.
For a more detailed description about how to be an effective self advocate, please review the leaflet entitled “How to Be An Effective Advocate” which is enclosed in this packet.
Following through on an insurance complaint:
1. Review your policy and locate the information that concerns the situation.
2. Gather together all of the information about the situation (letters of denial of coverage, itemized medical bills, any other relevant documents). Once this has been done, you can decide whether there is a case and how you would like to pursue it.
3. The first attempt at resolving the problem should be with the company and/or agent involved. A letter of complaint serves as reinforcement to phone contact. Make copies of any information you provide to the company and/or agent and give them the copies. ALWAYS KEEP YOUR ORIGINALS!
4. If insurance companies refuse to pay all or part of a charge because it exceeds their usual customary and reasonable (UCR) allowance, many providers who feel their charges are justified may be happy to help with your insurance complaint. [If in price comparing, you feel the providers charges are in excess of the norm, it will be the provider that you want to approach with your complaint.]
5. If you are still not satisfied after dealing with the insurer, a complaint can be registered with the Department of Insurance by calling (217) 782-7446. Or by email their address is:
DEPARTMENT OF INSURANCE
Consumer Complaint
320 W. Washington St.
Springfield, IL 62767
They handle walk-in, phone and written complaints. It’s a good idea to phone them first. They will help you determine the legitimacy of your complaint.
What happens to the complaint?
The department contacts the insurer on your behalf, reviews the complaint and response, and determines whether the company’s actions are in violation of a Statute, Departmental Rule, Regulation or position. If it is, they will take action to resolve the problem. If the Department of Insurance cannot help you, they will advise you of your alternatives.
Another Option–Illinois Attorney General’s Health Bureau
The Illinois Attorney General’s office has established a Health Care Bureau in the Consumer Protection Division. The Office operates a toll-free hotline dedicated to taking complaints concerning health and managed care. The hotline assigns a mediator to every case who will make an effort to resolve problems with managed care organizations, indemnity insurance companies, hospitals, nursing homes and other health care providers on the consumer’s behalf.
Complaints can be filed by calling the hotline at (877) 305-5145, sending an email through the Attorney General’s website at www.ag.state.il.us/Health Care/hcumain.html or by submitting a complaint to the following:
Office of the Attorney General
Health Care Bureau
100 West Randolph Street, 12 floor
Chicago, Illinois 60601
Still not satisfied?
Write to your local State Representative and Senator.
Note: The preceding advice is not legal advice, and should not be considered as such. It is solely information that has been gathered through the experiences of volunteer advocates working with the Consumer Health Hotline since 1980. If you need legal advice, you should contact an attorney.
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