Company complaint reasons descriptions

Reason information is divided into four categories: Claim handing, marketing and sales, policy holder services, and underwriting. A single complaint can have multiple reasons why it was submitted. All of the categories have subcategories that describe a more specific reason for complaint within the primary category.

Categories


Updated 02/2011

Claim handling subcategories

Adjuster Handling: Complaint alleging unsatisfactory handling of a claim by an adjuster.

Prompt Pay: Complaint alleging insurer's failure to comply with state prompt pay laws.

Willing Provider: Complaint alleging insurer's failure to comply with a state's any willing provider law.

Participating Provider Availability: Complaint alleging that no in-network provider available, and that a claim processed at the out-of-network benefit level should be reprocessed as an in-network claim.

Unsatisfactory Settlement / Offer: Complaint that insurer's payment or settlement offer is less than or below the amount expected by the insured or claimant.

Pre-existing Condition: Complaint alleging insurer's improper claim denial or coverage exclusion based on preexisting condition.

Medical Necessity Denial: Complaint alleging that the insurer has improperly denied covered services as not
medically necessary.

Fraud: Complaint alleging some form of claim-related deception or unfair practice by a third party resulting in unfair financial or compensable gain.

Post-Claim Underwriting: Complaint alleging inappropriate reclassification of a risk after a claim (insurer may be trying to reduce or eliminate the amount of loss by rescinding the policy, excluding certain risks, or increasing the premium due).

Subrogation: Complaint alleging improper subrogation activity by insurer.

Contributory / Comparative Negligence: Complaint regarding insurer's assessment/assignment of negligence for a claim to which contributory or comparative negligence law applies.

Claim Denial: Complaint alleging improper claim denial by insurer.

Usual, Customary, and Reasonable (UCR) Charges: Complaint alleging that the insurer's "usual, customary and reasonable" reimbursement amounts are inadequate.

Out-of-Network Benefits: Complaint regarding dissatisfaction with the administration or determination of benefits on a claim for services that have been requested, received or determined to be out-ofnetwork.

Co-pay, Deductible, and Co-Insurance Issues: Complaint alleging that the incorrect co-pay, deductible or co-insurance amounts have been applied to a claim.

Coordination of Benefits: Complaint alleging one or both insurers' failure to properly coordinate benefits.

Authorization Dispute: Complaint alleging that the insurer has improperly denied claim or assessed a penalty
on the basis of required preauthorization not having been obtained.

Primary Care Physician Referral: Complaint regarding consent given by a designated health care provider to visit another physician or health care provider.

Claim Delay: Complaint alleging that the insurer has unreasonably delayed the investigation and/or
processing of a claim.

Assignment of Benefits: Complaint alleging insurer's wrongful handling of insured's assignment of benefits.

Vehicle Repairs: Complaint regardinga dispute about vehicle repairs.

Cost Containment: Complaint alleging insurer's misapplication of cost-containment measures such as precertification, utilization review, concurrent review, managed care, second opinion, etc.

Appeal Non-compliance: Complaint alleging insurer’s failure to comply with statutory process requirements for appeals, grievances, or external review

Claim recoding/bundling: Complaint alleging insurer’s improper bundling of procedure codes or claim recoding by insurer.

Recoupment: Complaint alleging that the insurer has made improper attempts to recoup monies from provider.

Other – Claim Handling: Complaint that does not clearly fit in any other Claim Handling category.

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Marketing and sales subcategories

Premiums Misquoted: Complaint alleging that the insurer/agent misquoted premiums for the policy in question.

Failure to Submit Application: Complaint alleging that the agent failed to submit consumer's application to insurer, or failed to process request for coverage change.

Excess Compensation Without Agreement: Inappropriate charging of additional fees or amounts outside of premium.

Other Violation of Insurance Law/Regulation: Violation of a provision of law or regulation not specified in another category

Adjuster Working for a Company Not Licensed: Adjuster working for a company not licensed.

Using an Unlicensed Name: Conducting business in the state using an unlicensed name.

Unfair Discrimination: Complaint alleging discriminatory marketing and/or sales practices by a regulated entity
or individual.

Suitability: A complaint regarding the marketing and/or sales practices for a product and whether
the regulated entity or individual had reasonable grounds for believing the recommendation to purchase or exchange an insurance product was suitable for the targeted group or prospect on the basis of the facts disclosed by that group or prospect.

Financial Privacy: Complaint regarding the protections taken by an insurer or their representative (or lack
thereof) to ensure privacy of financial information.

Misleading Advertising: Complaint alleging unacceptable insurance or regulated product promotion which is
misleading in fact or product nature.

Health Privacy: Complaint regarding the protections (or lack thereof) to ensure privacy of health
information.

Replacement: Complaint alleging that the insurer or representative improperly substituted a new policy
for an existing policy, traded excessively to increase commissions or replaced an
existing policy with a new policy where this action did not benefit or was detrimental to
the insured.

Unauthorized Entity: Complaint regarding the marketing and/or sales practices of an entity or individual not
licensed or authorized to conduct business in the state where the product was marketed
or sold.

Fiduciary Theft: Complaint alleging theft by a trusted fiduciary (guardian, trustee, executive, employer or
administrator).

Misrepresentation: Complaint alleging that the insurer or representative made misleading or untrue
statements about policy terms, benefits, or about insurance during the marketing/sales
process.

Misappropriation of Premium: Complaint alleging wrongful use of premiums by the insurer, or insurer representative.

High Pressure Tactics: Complaint alleging that the insurer or representative used force, fright, or threat to
market insurance.

Duplication of Coverage: Complaint alleging that an insurer or its representative has improperly marketed or
issued multiple policies that simultaneously cover a single risk.

Rebating: Complaint alleging that the insurer or its representative has improperly offered the
prospect a special inducement (such as a share of the agent's commission, etc.) to
purchase a policy.

Misstatement on Application: Complaint alleging that the insurance application contained false or incorrectly stated information.

Fraud / Forgery: Complaint alleging a fraudulent act, including unauthorized alteration of documents by
an insurer or its representative in the marketing and sales process.

Excess Compensation Without Agreement: Complaint alleging that an insurer or its representative charged fees that are not allowed, or that exceed the allowable amount.

Other – Marketing & Sales: Complaint does not clearly fit in any other Marketing & Sales reason code.

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Policyholder services subcategories

Credentialing Delay: Complaint alleging delayed credentialing process.

Involuntary Termination by Plan: Complaint alleging improper termination of provider contract by insurer.
Provider Listing Dispute: Complaint alleging improper reflection of provider participation status in insurer's
directory.

Delayed Appeal Consideration: Complaint alleging insurer's failure to process a health insurance appeal within the required time frame.

Delayed Authorization Decision: Complaint alleging insurer's delayed response to healthcare authorization request.

Access to Fee Schedule/Rates: Complaint alleging that the insurer will not release adequate reimbursement schedule information.

Inadequate Reimbursement Rates: Complaint alleging that the insurer's contracted reimbursement rates are too low.

Unfair Negotiation: Complaint alleging unfair contract negotiation tactics by insurer.

Closed Network/Provider Discrimination: Complaint regarding insurer's refusal to admit provider to network, due to lack of need.

Class Action: Complaint regarding class action lawsuit against the insurer, a request for assistance in
selecting a settlement option, etc.

Exchange: Complaint alleging inadequate and/or delayed service by the insurer, in conjunction with the surrender or exchange of a life insurance or annuity product for another qualifying product.

Premium Notice / Billing: Complaints alleging insurer's failure to send notice regarding premium due date,
premium increase/decrease, policy lapse, etc.

Surrender Problems: Complaints about delays in obtaining a surrender, or surrender costs.

Cash Value: Complaints alleging the insurer's inaccurate calculation or accounting of policy cash value, dividends, loans, etc.

Accelerated Benefits: Complaint alleging insurer's improper handling of insured's accelerated or "living"
benefits (which are generally used in the event of a terminal illness.)

Delays / No Response: Complaint alleging untimely response to, or failure to respond to, policyholder request
for information.

Delivery of Policy: Complaint alleging insurer's delayed delivery of, or failure to deliver, an insurance policy
to the insured.

Unsatisfactory Refund of Premium: Complaint alleging insurer or their representative failed to properly refund an unearned premium.

Nonforfeiture: Complaint alleging that the insurer has not honored insured's non-forfeiture rights.

Viatical Settlement: Complaint alleging improper administration of viatical settlement.

Payment Not Credited: Complaint alleging insurer's failure to properly credit insured's payment to the insurer.

Coverage Question: Complaint alleging insurer's inadequate response to insured's request for information on
policy status or coverages, or for interpretation of policy provisions.

Access to Care: Complaint alleging that needed care is inaccessible, due to refusal of primary care
physician to authorize specialist care, or due to inadequate provider network (refusal of
participating providers to accept new patients, excessive wait times for appointment,
excessive distance to participating providers, etc.).

Abusive Service: Complaint alleging rude, threatening, or other coercive or unprofessional behavior
(other than "twisting" or "churning") by the insurer or its representative.

Provider Listing Dispute – Complaint alleging improper reflection of provider participation status in insurer’s directory.

Other -- Policyholder Service: Complaint does not clearly fit into any other Policyholder Service reason code.

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Underwriting subcategories

Premium & Rating: Complaint regarding a disagreement, inquiry, or question about insurer's premium/rating
structure, or manual rules (ratings). Includes complaints alleging that the insurer improperly classified the applicant as a higher risk than it should have, resulting in an improperly high premium.

Refusal to Insure: Complaint regarding insurer's decision to decline requested policy and/or coverage, based on the level of risk indicated in the policy application.

Cancellation: Complaint alleging the insurer's improper cancellation of a policy and/or coverage before the expiration date.

Non-renewal: Complaint alleging insurer's failure to (or decision not to) offer policy renewal, and/or insurer's
failure to notify consumer.

Credit Report: Complaint regarding the use of credit report in the underwriting process. Insurer's failure to provide adequate notice that credit report had been ordered, etc.

Underwriting Delays: Complaint alleging unreasonable delays in insurer's underwriting process, and/or delays
in responding to insured's inquiries regarding underwriting status.

Forced Placement: Complaint regarding the process of obtaining insurance through a tender or mortgagee.

Audit Dispute: Complaint regarding insurer's risk review after the policy period, leading to changes to
the original policy premiums or coverages.

Unfair Discrimination: Complaint alleging the insurer's unequal or unfair treatment of an insured or class of
insureds, based on race, ethnicity, gender, domestic violence, etc.

Rescission: Complaint regarding insurer's rescission (voiding) of a policy, based on material
misstatements on the original application for insurance.

Surcharge (homeowner's insurance or Safe Driver Incentive Program - SDIP): Complaint regarding a homeowners insurance premium surcharge, or an SDIP auto insurance premium surcharge based on claims, underwriting, and/or moving violations.

Endorsement / Rider: Complaint regarding insurer's handling of endorsements and/or riders added to
insurance policy, expanding or limiting the benefits payable or the risks covered.

Group Conversion: Complaint regarding the insured's conversion from group to individual coverage (with
same carrier) following termination from the group plan.

CLUE Reports: Complaint regarding the insurer's use of CLUE reports in underwriting property and
casualty insurance.

MIB Reports: Complaint regarding the insurer's use of MIB reports in underwriting life and health
insurance.

Continuation of Benefits: Complaint regarding COBRA (Comprehensive Omnibus Budget Reconciliation Act)
enrollment and/or coverage after the insured no longer qualifies for group coverage.

Other -- Underwriting: Complaint does not clearly fit in any other underwriting reason.

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See also