Department of Insurance explains top complaints received from consumers

Lieutenant Governor and Insurance Director Mary Taylor announced the Ohio Department of Insurance helped Ohio consumers save or recover $24.5 million in 2014 while assisting nearly 230,000 Ohioans mainly through its toll-free hotlines, community outreach efforts and counseling sessions. Over the past four years the Department has saved or recovered $84 million (2011- $11.6 million, 2012 – $24.4 million, 2013 – $23.5 million, 2014 – $24.5 million) for Ohioans.

Taylor also said denial of claim/adverse benefit determination was the top complaint reason the Department received in 2014. Health insurance was the type of coverage consumers most complained about.

“Protecting consumers while helping Ohioans better understand their insurance coverage is one of our top priorities,” Taylor said. “We want Ohioans to know they can turn to the Ohio Department of Insurance for free assistance when evaluating the different coverage options available to them. They can also file insurance-related complaints that we will investigate on their behalf.”

The Department’s savings and recovery figure for 2014 includes a new program record $18 million by its Ohio Senior Health Insurance Information Program (OSHIIP) and $6.5 million from its Office of Consumer Affairs, which addresses non-Medicare insurance matters.

The following lists show the top types of consumer complaints in 2014 for Ohio from the total of 6,450 received by the Department’s Office of Consumers Affairs. The national information is closed complaint data as of Dec. 29, 2014 provided by the National Association of Insurance Commissioners (NAIC).

Top Types of Ohio Consumer Complaint Reasons:

1. Denial of Claim/Adverse Benefit Determination – 39.7%
2. Claim Settlement/Payment Delay – 16.9%
3. Claim Settlement/Unsatisfactory Offer – 12%
4. Underwriting/Cancellation or Non-Renewal – 6.9%
5. Policy Service/Premium Notice Billing – 6%

Top Types of National Consumer Complaint Reasons:

1. Claim Settlement/Payment Delay – 19.4%
2. Denial of Claim/Adverse Benefit Determination – 16.3%
3. Claim Settlement/Unsatisfactory Offer – 10.8%
4. Underwriting/Cancellation or Non-Renewal – 5.1%
5. State Specific – 4.8%

Top Types of Ohio Consumer Complaints by Coverage:

1. Accident and Health – 44.7%
2. Personal Auto – 23%
3. Homeowners and Renters – 12.8%
4. Life and Annuity – 12%
5. Other Coverage – 7.4%

Top Types of National Consumer Complaint Reasons by Coverage:

1. Accident and Health – 41.6%
2. Personal Auto – 29.8%
3. Homeowners and Renters – 17%
4. Life and Annuity – 7%
5. Other Coverage – 4%

Insurance Claim Tips:

• Know Your Policy: Your policy is a contract between you and your insurance company.  Know what’s covered, what’s excluded and deductible amounts.
• File Claims as Soon as Possible: Call your agent or your company’s claims hotline right away.
• Provide Complete, Correct Information: Incorrect or incomplete information can cause a delay in processing your claim.
• Ask Questions: If there is a disagreement about the claim settlement, ask the company for the specific language in the policy that is in question. Determine if the disagreement is because you and the insurance company interpret your policy differently. If this disagreement results in a claim denial, make sure you obtain a written letter explaining the reason for the denial and the specific policy language under which the claim is being denied.
• Do Not Rush into a Settlement: If the first offer made by an insurance company does not meet your expectations, be prepared to negotiate to get a fair settlement. If you have any questions regarding the fairness of your settlement, seek professional advice.
• Health Claims: Ask your physician to provide your insurance company with details about your treatment, medical conditions and prognosis. If you suspect a provider is overcharging, ask the insurance company to audit the bill and verify whether the provider used the proper billing procedure.

Ohio consumers who would like to file a complaint or have insurance questions can call the Department’s consumer hotline at 800-686-1526 or visit www.insurance.ohio.gov. If your inquiry is Medicare related, call OSHIIP at 800-686-1578. You can follow the Ohio Department of Insurance on Facebook and Twitter.