Consumer Insurance Complaints and the Texas Department of Insurance
When you buy insurance coverage, you might discover that your coverage works the way you expected. You might be getting less coverage and billed for the difference. TDI has tools for consumers who question suspicious practices, complain about bills, or ask for independent reviews of claim denials.
How can consumers use Texas Department of Insurance (TDI) services?
Consumers who have complaints against insurance companies, health maintenance organizations (HMOs), insurance agents, and adjusters can request help from The Texas Department of Insurance (TDI). Each year, Texans receive millions of dollars in refunds and additional claim payments.
What about my privacy?
When you file a complaint, you sign a consent form. Then, the information you share with TDI is only used as needed for the investigation. Medical records, financial information, and email addresses are usually confidential under state and federal law.
What kinds of complaints can TDI help me with?
TDI only assists with complaints against insurance companies and other companies they regulate such as:
- workers’ compensation insurance.
Get help with complaints about:
- deceptive advertising
- misrepresentation about policy coverage
- suspected insurance fraud
- late payment, slow payment, or improper denial of claims
- denial of health care treatment or service
- policies canceled and not renewed
- discriminatory rate increases
- poor customer service
What claims does TDI not help with?
Even when TDI can’t help directly, the reports allow TDI to identify patterns of problems with insurance companies, HMOs, agents, or adjusters. TDI can’t:
- decide who was at fault in an accident,
- settle a dispute between you and the insurance company if you have no way to prove what happened,
- make a company pay a claim unless the company violated insurance laws, or
- give legal advice or medical judgments.
Do insurance claims through government programs have consumer protection?
Yes. Insurance claims through government programs have extra pressure to follow federal and state laws to get paid. Strict billing and documentation requirements tend to provide more consumer protection.
I got a surprise medical bill. What can I do?
Double-check the wording in your policy and any paperwork you signed before treatment. A “surprise” insurance bill is when you get an unexpected bill or balance because:
- You used an in-network provider, and you still got billed for services that should be covered.
- You used an out-of-network provider who provided service at an in-network facility.
In both instances, the bills are generally covered and are not billed without your permission.
Does TDI oversee access to mental health providers and substance abuse treatment?
Yes. Mental health and substance abuse disorder is sometimes called MH/SUD. Health insurance companies are required to offer equal access, also called parity. You should have the same number of office visits for mental health or substance abuse treatment as you would get if you were sick in your body. If your insurance company does not follow these guidelines, report it, and TDI will investigate.
What if my health insurance denies my mental health and substance abuse disorder (MH/SUD) claim?
Ask the company why they denied your claim. Then, if you don't like the answer, request a free external review by an independent third party. Once that review is complete, the health insurance provider must obey that decision.
What should I do before I file a complaint?
Start by talking to your insurance company. Look at your policy paperwork for the customer service contact information with the toll-free number, email, and address. You can also use its Company Lookup tool.
How do I prepare to contact the insurance company?
- Look at your policy paperwork and find the policy number.
- If you already filed a claim, give them the claim number.
- Tell them what happened and what you want them to do about it.
- Follow up in writing.
- Be willing to provide proof by email, fax, or regular mail.
- Ask the company for an answer in writing.
What type of proof should I send?
Never send your originals. Copies of documents that serve as proof include:
- canceled checks
- advertising materials via email, print, screenshots, etc.
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