Department of Insurance Complaints: How to File a Complaint with DOI

State Insurance Departments report that dissatisfaction with claims settlements is the number one reason consumers file complaints with them. Sometimes it is the fault of the insurer and sometimes it is the fault of the policyholders for not having adequate coverage.

Today, I’ll walk you through the insurance claim complaint process. I will use the process here in the state of Georgia, where I live. The process in your home state will be very similar and can be found on any state’s Department of Insurance website. Or you can call your Insurance Department and they will probably tell you how or send you printed information about the complaint process.

You can file a complaint with the Insurance Department if you cannot resolve your dispute directly with your company. You can even file your complaint if you haven’t gone through the appraisal process (found in your policy).

The Division of Consumer Services of the Department of Insurance provides information to the consumer and investigates complaints about companies and producers. They handle most insurance issues related to home, business, auto, health, HMO, life, credit, dental, etc. Those issues can include coverage issues, claim disputes, premium issues, sales misrepresentations, policy cancellations, and refunds, just to name a few. They will also investigate a complaint against a public adjuster.

The Consumer Services Division does not:

o Give you legal advice or act as your attorney;
o Recommend an insurance company, agent or policy;
o Resolve a dispute when the only evidence is your word against the word of the adjuster, producer or company;
o Make determinations related to the facts of a case. For example, they will not determine who is at fault in an accident or determine the disputed value of damaged or stolen property;
o Resolve complaints against service providers, such as auto body shops and restoration contractors, unless the complaints involve the action of the insurance company. For example, they could resolve complaints against a restoration contractor that the insurance company required you to use;
o Make medical judgments.

The Insurance Department recommends:

o Read your policy carefully. It is important to know what your policy covers before you suffer a loss. If you have questions about the coverages you have purchased, ask your Agent for an explanation.

o Keep copies of all correspondence between you and the insurance company. When you contact your insurance company, keep a record of the phone numbers you called, the date and time of the call, and the name and title of the person you spoke with. After the call, take notes of what was discussed.

o Ask the company for specific language in the policy related to your claim. Determine if the disagreement is because you and the insurance company interpret your policy differently. If there is a disagreement over the language of the policy, you may seek assistance through the Division of Consumer Services by filing a complaint and providing documentation that will include the language of the disputed policy.

o If possible, take pictures or videos of its contents in your home and do so periodically, which will help in case of loss. Store photos or video in a safe or other place than at home.

AVOID AUTOMOBILE AND OWNER CLAIMS

o Keep all receipts for any repairs you make to your property after the damage. 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. Keep the damaged property for inspection by the claims adjuster. If possible, take photos or videos of the damage before making temporary repairs.
o Do not make permanent repairs until the adjuster has inspected the damage.
o Ask the adjuster for a detailed explanation of the claim settlement offer. For homeowner claims, this should include sales tax, depreciation, and withholding depreciation for policies with replacement cost coverage. Retained depreciation is an amount of money withheld from your claim settlement until repairs are completed or items are replaced. Ask how the adjuster determined the estimated amount.
o Be prepared to discuss your claim if there is a disagreement on the settlement offer. The more documentation you have on the items you own, the easier the process will be.

If you have a claim dispute, contact your insurance company first.

When you contact your insurance company, please have your policy number ready. Ask where your written dispute should be sent. State your complaint and how you expect the company to resolve it. Submitting the dispute in writing encourages a written response.

Document your phone calls by writing down the phone number you called, the name of the person you spoke to, the date of the call, and a brief summary of the conversation. Keep copies of all written communications.

In addition to the written complaint, send copies (not originals) of letters, notes, invoices, canceled checks, publicity materials, or other documents that support your complaint.

The DOI complaint form

The DOI complaint form is a document that can be completed, printed and sent with copies of the documents that support your complaint. Obtain this form on the DOI website or call them and request that a copy be mailed to you. This will allow them to prepare a case and will eliminate the need to request documents and reduce the delay in providing a response. Always keep your original documents for your records.

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

* your name, address, daytime telephone number and email address

* 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

* copies of all supporting documentation, including invoices, canceled checks, publicity material, and any letters between you and the company or agent.

What will the Insurance Department do to resolve your complaint?

* Send a copy of your complaint to the entity you complained against and request a detailed response in writing.

* Determine if your problem was handled properly according to the terms of the policy or certificate of coverage.

* Review your file to determine if the insurance company, insurance agent, or adjuster violated state insurance laws.

* Take action to enforce laws when laws are violated.

Although they may not always be able to help you resolve your complaint, your complaints and inquiries help DOI assist other policyholders by identifying issues of concern and can help identify potential issues with insurance companies, agents, or adjusters. Your involvement can also lead insurance companies to take a closer look at your concerns.

What happens after I file a complaint with the Department of Insurance?

* You will receive an acknowledgment letter, informing you who the investigator is and their contact information. Your case number shown on the letter is for the problem presented to the Department. The case number should be used to send additional information to the Department about your case.

* If you have complaints in the future, you will receive a new case number, an acknowledgment letter, and the name of the new investigators and contact information.

* DOI will notify the company of your complaint and ask for a detailed response. They will send you a copy of the company’s response, with your formal letter regarding the completion of our investigation. The review will result in one of the following actions:

o If the complaint has been resolved, they will send you a letter explaining the resolution.

o If an insurance law has been violated, they will request corrective action from the company.

o If the company does not comply with the policy, it will request corrective action.

o If the insurer or producer has not answered all the questions or has not investigated the complaint thoroughly, it will require them to do so.

What if you are not satisfied with the results of the Insurance Department?

If you do not agree with the Department’s response to your complaint, contact the Division of Consumer Services and ask to speak with a Supervisor.

You may want to consult an attorney to discuss your concerns. You can also request alternative dispute resolution (ADR) to resolve disputes with your insurance company about property claims. ADR uses techniques such as mediation with a neutral third party to help resolve a dispute outside of a formal court of law. Consult your telephone directory for listings of attorneys and mediation services.

You now have a basic understanding of the complaint process. Remember, Departments of Insurance exist to regulate insurance companies and protect consumers. Don’t be ashamed to ask for their help. That is why they exist.