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 also can call your company to get a copy or visit our Consumer Bill of Rights web page.
- 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 your phone calls to the company 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 your 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 (expected outcome).
- 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 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.