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Helping You with Your Insurance Complaint

(April 2017)

(En Español)

What We Can Help With | Before You File a Complaint | File Your Complaint | Be Claim Smart | Workers’ Compensation Claim Related Complaints | Get Help From TDI

The Texas Department of Insurance helps consumers resolve complaints against insurance companies, health maintenance organizations (HMOs), insurance agents, and adjusters. Each year, we help thousands of Texans get millions of dollars in additional claim payments and refunds.

To file a complaint, visit our website.

Note about privacy: To help resolve your complaint, we need to share the information you send us with the person or company named in your complaint. You’ll have to sign a consent form allowing us to share the information. If you don’t sign the consent form, we might not be able to fully help you.

Also, be aware that some of the information you give us can be released to anyone who requests it under the Texas Public Information Act. We will not release information that is confidential, however. Medical records, financial information, and email addresses are generally confidential under state and federal law and will not be released.

What We Can Help With 

TDI can help you resolve complaints about property, title, health, and workers’ compensation insurance. We can only help with complaints against insurance companies and people we regulate. We don’t have jurisdiction over service providers, including body shops, building contractors, and doctors. If you have a complaint against a service provider, send it to the licensing or enforcement agency that regulates the provider.

We can help with these types of complaints:

  • late or slow payment of claims;
  • policy cancelations and nonrenewals;
  • improper claim denials;
  • health care treatment or service denials;
  • poor customer service;
  • misrepresentation about what a policy covers;
  • discriminatory rate increases;
  • false or misleading advertising; and suspected insurance fraud.

While we make every effort to help you resolve your complaint, there are certain issues that we can’t help you resolve. We can’t:

  • find out who was at fault in an accident;
  • settle a dispute between you and the insurance company when the only evidence is your word;
  • make a company pay a claim if the company’s refusal to pay the claim didn’t violate any insurance laws or rules; or
  • give legal advice or make medical judgments.

Even if we can’t resolve your complaint, your complaints and questions help us identify issues and potential problems with insurance companies, HMOs, agents, or adjusters. Our involvement may also cause companies to look more closely at your concerns.

Health Plan Complaints 

There are two kinds of health plans, fully funded health plans and self-funded plans.

A fully funded plan is one in which the insurance company or HMO assumes the total risk for paying claims. Most health plans offered through small- and medium-sized employers are fully funded.

A self-funded health plan is one in which the employer pays claims itself. The employer may hire an insurance company, HMO, or someone else to handle claims and paperwork. Many large employers have self-funded plans. For more information about self-funded plans, read TDI’s publication Understanding Employer Self-Funding of Employee Health Benefits.

TDI can help you resolve complaints against fully funded health plans.. Self-funded plans are regulated by federal law and are under the jurisdiction of the U.S. Department of Labor.

If you have a complaint against a self-funded health plan offered by a government or church employer, follow the complaint procedures in your benefits booklet and other plan documents.

If the plan is self-funded and offered by a private-sector employer or union, file a complaint with the Dallas Regional Office of the U.S. Department of Labor’s Employee Benefits Security Administration:

525 South Griffin St, Room 900
Dallas, Texas 75202

If you’re not sure what kind of plan you have, look at your health plan card. If it says “TDI” or “DOI,” you have a fully funded health plan. You can also talk to the benefits administrator where you work.

Before You File a Complaint 

Call your insurance company first. Many complaints can be resolved by talking to the company about your issue.

Most insurance companies have a toll-free customer help line.. The number is printed on your policy. You can call our Consumer Help Line to get the company’s number and address. You can also use the Company Lookup feature on our website.

When you call your insurance company:

  • have your policy number ready. If you’ve already filed a claim, have your claim number too.
  • follow up in writing. Describe your complaint and how you want the company to resolve it.
  • Send copies (not originals) of letters, notes, invoices, canceled checks, advertising materials, or other documents that support your complaint.
  • ask the company to send you  a written response.

Issues with your auto or homeowners insurance

Most auto and homeowners policies have an appraisal process for resolving disputes about the amount of damages your company will pay. Ask your company if your policy has an appraisal process. You also have the right to appeal the company’s decision or to take the matter to court.

Issues with your health insurance

Most plans have a process for you to appeal a denied claim. If you appealed with your health plan and you're still not satisfied, you may be able to have an independent review organization (IRO) review the denial. TDI certifies IROs. If you get an IRO review, the insurance company or HMO must pay for the review and follow the IRO's decision.

File your Complaint

The first step to filing a complaint is to gather the information we’ll need to look into your complaint. That information includes:

  • your name, address, and daytime phone number;
  • the exact name of the insurance company;
  • the name of agents or adjusters involved;
  • your policy number;
  • your claim number and the date of your loss;
  • a copy of both sides of your insurance card, if appropriate;
  • a description of your problem;
  • what you believe would be a fair resolution of your complaint; and
  • copies of all supporting documents, including invoices, canceled checks, advertising materials, and any letters between you and the company or agent

There are two ways to file a complaint. You can use the Online Complaint Portal. You can also fill out a complaint form that is available on the Insurance Complaint Process page or by calling the Consumer Help Line. You may submit your form:

By mail: 
Texas Department of Insurance
Consumer Protection
MC 111-1A

P.O. Box 149091

Austin, Texas 78714-9091

In person: 

      Texas Department of Insurance
      Consumer Protection (111-1A)
      333 Guadalupe St.
      Austin, Texas 78701

By fax: 512-490-1007

By email: ConsumerProtection@tdi.texas.gov

Sending documents to support your case

If you use the online form to file your complaint, you can upload your supporting documents or photos through the Online Complaint Portal. If you use the paper form, you can send supporting documents with the form.

We can accept PDFs, Word, and Excel documents. We also can accept photos in JPG format. We can’t accept links to online documents, pictures, or videos.

What to Expect after You File a Complaint 

After you file your complaint with us, we’ll contact the company or agent your complaint is against and try to help resolve the dispute. When we work on your complaint, we will:

  • Send you a letter letting you know we’re working on your complaint. .
  • Tell the company about your complaint and ask for a detailed response.
  • Send you a letter with the company’s response and an explanation of the outcome. This will usually be within 60 days after we get your complaint,
  • Decide whether the company handled your issue within the terms of the policy or certificate of coverage.
  • Decide whether the company, agent, or adjuster broke state insurance laws. If a law was broken, we can take enforcement action.

If You’re Not Satisfied

If you’re not satisfied with the outcome of your complaint, you may discuss your concerns with an attorney. If you’re complaint involves an auto or homeowners insurance policy, you may ask for alternative dispute resolution (ADR). ADR uses mediation with a neutral third party to settle disputes outside court.

If you need help finding an attorney, visit the State Bar of Texas Lawyer Referral and Information Service website or call 1-800-252-9690.

Be Claim Smart 

Most of the complaints we deal with involve disputes about claim settlements. Follow these tips to help avoid problems:

  • Read your policy carefully. A policy is a contract between you and the insurance company or HMO. Don’t rely on your agent to tell you what your policy covers.
  • Read the Consumer Bill of Rights. The Consumer Bill of Rights explains your rights and responsibilities. Most insurance companies are required to include a copy of the Bill of Rights with your policy. You can also call your company to get a copy or visit our Consumer Bill of Rights website.
  • Keep copies of all documents and take notes about all calls you have with the insurance company or HMO. Include the date and what you talked about. Be sure to include the name and title of the person you spoke with.
  • Follow up phone calls with an email or letter.
  • Ask the company to show you what language in the policy it’s using to settle your claim. The disagreement might be because you and the insurance company or HMO read your policy differently.

Auto and Homeowner Claim Tips

  • Keep all receipts for repairs you make to your damaged property. Auto and homeowners policies may require you to make reasonable temporary repairs to prevent further damage. Your policy covers the cost of these repairs. If possible, take pictures or videos of your damaged property before making any repairs.
  • Don’t make permanent repairs until the adjuster has inspected the damage. Keep the damaged property for the claims adjuster to inspect. Try to be there when the adjuster looks at your property.
  • Ask the adjuster for an explanation of the claim settlement offer. For homeowners claims, the claim settlement offer will include a list of your damaged items, along with their replacement cost value and depreciation. Find out how the adjuster got the cost estimates.
  • Be prepared to negotiate. If your repair or replacement estimates are higher than the company’s settlement offer, talk to your adjuster. If you have original sales receipts, advertisements, or other documents that show a higher replacement cost, give them to your adjuster. You can also have your contractor and the adjuster talk about repair or replacement costs.
  • Save receipts for the items you replace. If you have replacement cost coverage, you’ll have to show that you actually replaced an item before the company will pay you fully for it.

Accident and Health Claim Tips

  • Ask your doctor to provide your insurance company or HMO with details about your treatment, medical condition, and prognosis.
  • Have an independent review organization (IRO) review treatment denials. If your insurance company or HMO denies a treatment because it said the treatment wasn’t medically necessary or appropriate, you may be able to have an IRO review. Independent reviews are available if Texas law requires your plan to participate, or if the plan voluntarily participates, in the IRO process. You must appeal the denial with your health plan before asking for an IRO review. For more information, call TDI’s IRO Information Line at 1-866-554-4926. You may also email URAGrp@tdi.texas.gov.
  • Consider mediation. If you have health coverage through a preferred provider plan and have a dispute about an outstanding bill from an out-of-network hospital-based doctor, you might be able to resolve your dispute through mediation. If you choose mediation, the doctor and your plan will meet to discuss the bill. If the mediation is unsuccessful, you might have to resolve the dispute in court. Visit our mediation website to learn more about mediation and whether you qualify.

Deadlines for Payment of a Claim

Texas law requires insurance companies to pay claims within certain time frames. Most licensed insurance companies must:

  • Begin investigating your claim within 15 days after getting it.
  • Accept or reject your claim in writing within 15 business days after getting all required information. This deadline may be extended another 15 days in the event of a declared disaster. If the company needs more time, it must tell you why it needs more time. It will then have up to 45 additional days to accept or reject your claim.
  • Tell you in writing why it denied your claim.
  • Pay you within five business days after telling you it will pay your claim.

The laws about paying claims within certain time frames don't apply to liability insurance claims against another person’s insurance company. For instance, if you’re in a wreck caused by another driver and your claim is against the other driver’s insurance company. These laws also don’t apply to claims involving:

  • self-funded health plans;
  • workers’ compensation insurance;
  • mortgage guaranty or title insurance;
  • fidelity, surety, or guaranty bonds; and
  • marine insurance (other than inland marine).

Workers’ Compensation Claim-Related Complaints 

Workers' compensation pays your medical bills and replaces some of your lost wages if you have a work-related injury or illness and your employer has workers’ compensation insurance. In Texas, most employers can choose whether to provide workers' compensation coverage for their employees. Your employer must tell you if it provides coverage.

To file a workers’ compensation claim-related complaint, visit the Workers’ Compensation Complaints website. For help filing a complaint, call 1-800-252-7031, between 8 a.m. and to 5 p.m., Central Time, Monday to Friday.

If you have a dispute about your workers’ compensation claim, call your local Division of Workers’ Compensation field office. Workers’ compensation claims disputes are handled through a formal administrative process. For more information, call DWC at 1-800-252-7031.

Get Help from TDI

For insurance questions or for help with an insurance-related complaint, call the Consumer Help Line at 1-800-252-3439 or visit our website.

Visit HelpInsure.com to shop for automobile, homeowners, condo, and renters insurance, and TexasHealthOptions.com to learn more about health insurance and your options for coverage.

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:

Last updated: 04/13/2017

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