A complaint can be submitted for one or more of the following reasons:
Adjuster handling: An adjuster unsatisfactory handled a claim.
Prompt pay: Insurer failed to comply with state prompt-pay laws.
Willing provider: Insurer failed to comply with a state's any-willing-provider law.
Participating provider availability: Because an in-network provider wasn’t available, a claim processed at the out-of-network benefit level should be reprocessed as an in-network claim.
Unsatisfactory settlement/offer: Insurer's payment or settlement offer less than the amount expected by the insured or claimant.
Pre-existing condition: Insurer improperly denied a claim or excluded coverage based on a pre-existing condition.
Medical necessity denial: Insurer improperly denied covered services as not medically necessary.
Fraud: A claim-related deception or unfair practice by a third party, resulting in unfair financial or compensable gain.
Post-claim underwriting: 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.)
Subrogation: Improper subrogation activity by insurer.
Contributory/comparative negligence: Insurer's assessment/assignment of negligence for a claim to which contributory or comparative negligence law applies.
Claim denial: Improper claim denial by insurer.
Usual, customary and reasonable (UCR) charges: Insurer's "usual, customary and reasonable" reimbursement amounts are inadequate.
Out-of-network benefits: Dissatisfaction with the administration or determination of benefits on a claim for services that has been requested, received, or determined to be out-of-network.
Copay, deductible and coinsurance issues: Incorrect copay, deductible or coinsurance amounts have been applied to a claim.
Coordination of benefits: One or both insurers' failure to properly coordinate benefits.
Authorization dispute: Insurer has improperly denied a 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: Insurer has unreasonably delayed the investigation and/or processing of a claim.
Assignment of benefits: Insurer's wrongful handling of insured's assignment of benefits.
Vehicle repairs: A dispute about vehicle repairs.
Cost containment: Insurer's misapplication of cost-containment measures such as precertification, utilization review, concurrent review, managed care, second opinion, etc.
Appeal non-compliance: Insurer’s failure to comply with statutory process requirements for appeals, grievances or external review.
Claim recoding/bundling: Insurer’s improper bundling of procedure codes or claim recoding.
Recoupment: 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.
Marketing and sales complaint allegations
Premiums misquoted: Insurer/agent misquoted the policy’s premiums.
Failure to submit application: Agent failed to submit consumer's application to insurer or failed to process request for coverage change.
Excess compensation without agreement: Inappropriately charging additional fees or amounts in addition to the premium.
Other violation of insurance law/regulation: Violation of a provision of law or regulation not specified in another category.
Adjuster working for an unlicensed company: Adjuster working for a company that is not licensed.
Using an unlicensed name: Conducting business in the state using an unlicensed name.
Unfair discrimination: Discriminatory marketing and/or sales practices by a regulated entity or individual.
Suitability: The regulated entity or individual didn’t have reasonable grounds for recommending the purchase or exchange of an insurance product suitable for the targeted group or prospect, based on the facts disclosed by that group or prospect.
Financial privacy: Protections by an insurer or its representative (or lack thereof) were insufficient to ensure the privacy of financial information.
Misleading advertising: Unacceptable promotion of insurance or a regulated product which is misleading in fact or product nature.
Health privacy: Insufficient protections to ensure privacy of health information.
Replacement: Insurer or its 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: 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: Theft by a trusted fiduciary (guardian, trustee, executive, employer or administrator).
Misrepresentation: Insurer or its representative made misleading or untrue statements about the policy’s terms, benefits, or about insurance during the marketing/sales process.
Misappropriation of premium: Wrongful use of premiums by the insurer or insurer representative.
High-pressure tactics: Insurer or its representative used force, fright or threat to market insurance.
Duplicate coverage: Insurer or its representative improperly marketed or issued multiple policies that simultaneously cover a single risk.
Rebating: Insurer or its representative improperly offered the prospect a special inducement (such as a share of the agent's commission) to purchase a policy.
Misstatement on application: Insurance application contained false or incorrectly stated information.
Fraud/forgery: Fraud, including unauthorized alteration of documents by an insurer or its representative during the marketing and sales process.
Excess compensation without agreement: Insurer or its representative charged fees that are not allowed, or that exceed the allowable amount.
Other marketing and sales: Complaint does not clearly fit in any other marketing and sales reason code.
Policyholder services complaint allegations
Credentialing delay: Delayed credentialing process.
Involuntary termination by plan: Improper termination of provider contract by insurer.
Provider listing dispute: Improper reflection of provider participation status in insurer's directory.
Delayed appeal consideration: Insurer failed to process a health insurance appeal within the required timeframe.
Delayed authorization decision: Insurer's delayed response to healthcare authorization request.
Access to fee schedule/rates: Insurer will not release adequate reimbursement schedule information.
Inadequate reimbursement rates: Insurer's contracted reimbursement rates are too low.
Unfair negotiation: Unfair contract negotiation tactics by insurer.
Closed network/provider discrimination: 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: Insurer’s inadequate and/or delayed service regarding the surrender or exchange of a life insurance or annuity product for another qualifying product.
Premium notice/billing: Insurer's failure to send notice regarding premium due date, premium increase/decrease, policy lapse, etc.
Surrender problems: Delays in obtaining a surrender, or surrender costs.
Cash value: Insurer's inaccurate calculation or accounting of policy cash value, dividends, loans, etc.
Accelerated benefits: 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: Insurer’s untimely or omitted response to policyholder’s request for information.
Delivery of policy: Insurer's delayed or failed delivery of an insurance policy to the insured.
Unsatisfactory refund of premium: Insurer or its representative failed to properly refund an unearned premium.
Nonforfeiture: Insurer has not honored insured's non-forfeiture rights.
Viatical settlement: Improper administration of viatical settlement.
Payment not credited: Insurer's failure to properly credit insured's payment to the insurer.
Coverage question: Insurer's inadequate response to insured's request for information on policy status or coverages, or for interpretation of policy provisions.
Access to care: Needed care is inaccessible due to refusal of primary care physician to authorize specialist care, or due to inadequate provider network, i.e., refusal of participating providers to accept new patients, excessive wait times for appointment, excessive distance to participating providers, etc.
Abusive service: Rude, threatening or other coercive or unprofessional behavior (other than "twisting" or "churning") by the insurer or its representative.
Other policyholder service: Complaint does not clearly fit into any other policyholder service reason code.
Underwriting complaint allegations
Premium and rating: 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: Insurer's decision to decline requested policy and/or coverage, based on the level of risk indicated in the policy application.
Cancellation: Insurer's improper cancellation of a policy and/or coverage before the expiration date.
Non-renewal: Insurer's failure to (or decision not to) offer policy renewal, and/or insurer's failure to notify consumer.
Credit report: Misuse of credit report in the underwriting process, including insurer's failure to provide adequate notice that a credit report had been ordered.
Underwriting delays: 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:Insurer's risk review after the policy period, leading to changes to the original policy premiums or coverages.
Discrimination: Insurer's unequal or unfair treatment of an insured or class of insureds based on race, ethnicity, gender, domestic violence, etc.
Rescission: Insurer's rescission (voiding) of a policy, based on material misstatements on the original application for insurance.
Surcharge (homeowner insurance or safe driver incentive program - SDIP): Homeowner insurance premium surcharge, or an SDIP auto insurance premium surcharge, based on claims, underwriting, and/or moving violations.
Endorsement/rider: Insurer's handling of endorsements and/or riders added to insurance policy, expanding or limiting the benefits payable or the risks covered.
Group conversion: Insured's conversion from group to individual coverage (with same carrier) following termination from the group plan.
CLUE reports: Insurer's use of CLUE (Comprehensive Loss Underwriting Exchange) reports in underwriting property and casualty insurance.
MIB reports: 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.