State Departments of Insurance report that dissatisfaction with claim settlements is the top reason consumers file complaints with them. Sometimes it is the fault of the insurer, and sometimes it is the policyholders’ fault for not having the right coverage.
Today, I’m going to walk you through the process of filing an insurance claim complaint. I’m going to 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 at the website of any state’s Department of Insurance. Or, you can phone your Department of Insurance and they will likely either tell you how, or send you printed information on the complaint process.
You may file a complaint with the Department of Insurance if you cannot resolve your dispute directly with your company. You can even file your complaint if you haven't been through the appraisal process (found in your policy).
The Consumer Services Division of the Department of Insurance provides consumer information and investigates complaints about companies and producers. They handle most insurance problems involving home, business, auto, health, HMO, life, credit, dental, etc. Those problems may include coverage issues, claim disputes, premium problems, 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 will not:
• Give you legal advice or act as your attorney;
• Recommend an insurance company, agent or policy;
• Resolve a dispute when the only evidence is your word against the word of the adjuster, producer or company;
• Make determinations related to the facts of a case. For example, they will not conclude who is at fault in an accident or determine the disputed value of damaged or stolen property;
• Resolve complaints against service providers, like 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;
• Make medical judgments.
The Department of Insurance recommends:
• Read your policy carefully. It is important to know what your policy covers prior to having a loss. If you have questions on the coverages you have purchased have your Agent provide you an explanation.
• Keep copies of all correspondence between you and the insurance company. When communicating with your insurance carrier keep track of the phone numbers you called, the date and time of the call and the name and title of the individual you spoke with. After the call keep notes on what was discussed.
• Ask the company for the specific language in the policy related to your claim. Determine whether the disagreement is because you and the insurance company interpret your policy differently. If there is a disagreement on the language in the policy you can seek assistance through the Consumer Services Division by filing a complaint and providing the documentation which will include the policy language in dispute.
• If at all possible take pictures or videos of your contents in your home and do this periodically which will help in the event of a loss. Keep the pictures or video in a safe deposit box or somewhere other than the home.
AVOIDING AUTO AND HOMEOWNER CLAIMS
• Keep all receipts for repairs you make to your property after 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 the claims adjuster to inspect. If possible, take photos or videos of the damage before making temporary repairs.
• Don't make permanent repairs until the adjuster has inspected the damage.
• Ask the adjuster for an itemized explanation of the claim settlement offer. For homeowners claims, this should include sales tax, depreciation, and holdback depreciation for policies with replacement cost coverage. Holdback depreciation is an amount of money withheld from your claim settlement until repairs are finished or the items are replaced. Ask how the adjuster determined the estimate amount.
• Be prepared to discuss your claim if there is a disagreement on the settlement offer. The more documentation you have on items owned will make the process easier.
If you do have a claim dispute, contact your insurance company first.
When contacting your insurance company have your policy number ready. Ask where your written dispute needs to be sent. State your complaint and how you expect the company to resolve it. Sending the dispute in writing encourages a written response.
Document your phone calls by noting the phone number you called, the name of the person with whom you spoke, 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, advertising 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 submitted with copies of documents that support your complaint. Obtain this form at the DOI website or phone them and request a copy be sent to you by mail. This will enable them to set up a case and eliminate the need for them to request documents, and reduce the delay in providing a response. Always keep your original documents for your records.
To help ensure that the Department of Insurance receives all necessary information to investigate your complaint, 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, advertising materials, and any letters between you and the company or agent.
What will the Department of Insurance do to resolve your complaint?
* Send a copy of your complaint to the entity you complained against and request a detailed written response.
* Determine if your issue was handled appropriately under 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 enforcement action when laws are violated.
Even though they may not always be able to help you resolve your complaint, your complaints and inquiries help the DOI to assist other policyholders by identifying issues of concern and may help identify potential problems with insurance companies, agents, or adjusters. Their involvement can also cause insurance entities to look more closely at your concerns.
What happens after you file a complaint with the Department of Insurance?
* You will receive an acknowledgment letter, advising who the investigator is and their contact information. Your Case Number shown on the letter is for the issue submitted to the Department. The case number should be used to send additional information to the Department on your case.
* If you have future complaints you will get a new case number, acknowledgement letter and the new investigators name and contact information.
* The 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 their 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 by the company.
o If the company is not abiding by the policy, they will request corrective action.
o If the insurer or producer has not responded to all questions or has not investigated the complaint thoroughly, they will require them to do so.
What happens if you are not satisfied with Department of Insurance results?
If you disagree with the Department’s response to your complaint, contact the Consumer Services Division and ask to speak with a Supervisor.
You may wish to consult an attorney to discuss your concerns. You may also request alternative dispute resolution (ADR) to settle disputes with your insurance company on property claims. ADR uses techniques such as mediation with a neutral third party to help settle a dispute outside a formal court of law. Please consult your telephone book for listings for attorneys and mediation services.
Now you have a basic knowledge of the complaint process. Remember, the Departments of Insurance exist to regulate insurance companies and protect consumers. Don’t be shy about enlisting their help. That’s why they exist.