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Consumer Assistance Services/Consumer Outreach and Education Guide

Here is a printable PDF version: Consumer Assistance Services/Consumer Outreach and Education Guide

This consumer guide should be used for educational purposes only. Nothing in this guide is intended to be an opinion, legal or otherwise, of the State Corporation Commission, nor should it be construed as an endorsement of any organization, product, person, or service mentioned in this guide.

IMPORTANT CONTACT INFORMATION

Life and Health Consumer Services / Property & Casualty Consumer Services:

Office of Managed Care Ombudsman: Office of Independent External Review: Consumer Outreach / Education:

CONSUMER ASSISTANCE SERVICES

Life and Health / Property and Casualty Consumer Services

Consumer Services handles consumer inquiries and complaints concerning life, health, Medigap, long-term care, dental, disability, annuity, credit, auto, and homeowners' insurance. Consumer Services will investigate your complaint, help you understand your coverage and rights under your insurance policy, help you get a clear response to your question and verify the company or agent is complying with Virginia insurance laws and regulations.

The Bureau CANNOT recommend a particular insurance company, agent, or product, or provide legal services that are sometimes required to settle complicated problems. If we are not able to resolve your problem, we will explain why and if available, will suggest courses of actions that you may take in efforts to reach a resolution.

Complaint Assistance: 

Office of the Managed Care Ombudsman 
The Office of the Managed Care Ombudsman assists consumers in appealing an adverse determination made by their managed care health insurance plan. The Office will assist you in understanding the appeal process and help you file an appeal with the carrier. The Office will also help you understand how your managed care plan works, answer questions concerning your coverage, and explain regulatory requirements that apply to your health insurance plan. 

Office of Independent External Review 
Consumers who have exhausted the internal appeal process with their health insurance carrier, or in some cases self-insured ERISA plan, can request an independent external review of a denial if the denial was based on a determination that the care did not meet requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, or involved an experimental or investigational procedure. All appeals must be filed with the Bureau within 120 days of the date you receive notice of your right to an independent external review. The Bureau will randomly select an impartial Independent Review Organization (IRO) to conduct the independent external review. The IRO's decision is binding on the health insurance carrier or self-insured ERISA plan (if applicable) and on you except to the extent you have other remedies available under state or federal law.

Complaint Assistance:

  • To request assistance with a complaint from the Bureau's External Review Section, you may use the External Review Request Form – Form 216-A.
  • Additional guidance for submitting an External Review can be found in the "How do I submit an External Review?" section of the Bureau's website.

HELP IS AVAILABLE

Important Points to Consider 

Insurance Rules to Live By: 
  • Know the name of your insurance company and policy number. 
  • Read your policy. 
  • Be sure your agent is licensed. 
  • Get a receipt if you pay cash. 
  • Read the application before you sign it. 

Know Your Rights - Insurance companies: 

  • Required to pay claims promptly and fairly. 
  • Not allowed to unfairly discriminate as to premium rates charged or coverages or benefits provided. 
  • Must give the consumer access to certain information collected by the insurance company. 

Contact Your Agent or Company First 
If a mistake has been made, it often is easy to correct upon inquiry. 

  • Contact the company or agent by phone, letter, or email to explain the problem. 
  • Always keep copies of correspondence, such as letters, e-mail or fax communications for your records. 
  • If you contact the company or agent by telephone regarding your concerns, keep a written record of:
    • the date and time of your call;
    • the name and title of the person you talked to; and
    • what was said during the call.

 Contacting the Bureau: 

  • Briefly describe your complaint or appeal. 
  • Provide your name and the name of the insured person (if different), the name of the insurance company involved and the policy or group certificate number. 
  • Provide an explanation of your problem (i.e., what happened, who's involved, why you think the company/agent is wrong). 
  • Explain how you tried to resolve the problem. 
  • Explain what you think the company/agent should do to resolve the problem. 
  • Attach copies of: 
    • letters or e-mails you have written to the company/agent concerning your complaint/appeal and letters or e-mails the company/agent has written to you; 
    • notes from telephone conversations you may have had with the company/agent; 
    • your insurance policy or, for group health insurance, the part of your benefits handbook concerning the disputed coverage, mark the section you think supports your complaint; 
    • letters written by other persons (i.e., doctors or lawyers) concerning the problem; 
    • sales literature or worksheets (if this is relevant to your complaint); and 
    • the claim you filed with the insurance company.

How Soon Should I Expect a Response from the Bureau? 

  • Within three to five business days after we receive your complaint or appeal form, we will acknowledge receipt of your correspondence.

How Will the Bureau Contact the Insurance Company / Agent? 

  • In most cases, a letter and a copy of your complaint / appeal will be sent to the company / agent requesting an explanation of its position. After the company/agent responds, we will determine what further actions we will take. 

How Long Will the Process Take? 

  • Normally, it takes about 45 days after we receive a complaint to provide our final response. However, it may take longer if your complaint is claim related, involves a unique or complex problem, or requires the company or agent to conduct extensive research. 

Should I Call to Check on My Complaint / Appeal? 

  • You do not need to call. We will keep you informed and advise you of the outcome of our review. If you have additional information, send it to us. Include the file number we assigned in our letter of acknowledgment, and send it to the person investigating your complaint.

CONSUMER OUTREACH AND EDUCATION 

The Bureau of Insurance offers free consumer outreach programs on many insurance topics and participates in educational exhibits. Informative presenters are available to speak with your group or organization on the insurance topic of your choice and will answer general questions.

CONSUMER GUIDES

The Bureau of Insurance has consumer guides that provide important information about various lines of insurance, including Life, Health, Long Term Care, Medigap, Auto, Homeowners, Renters, Commercial, and Title Insurance, Teen Auto Insurance, Credit Scoring and Disaster guides are also available. These materials are designed to help you better understand the insurance policy you have purchased or are thinking of purchasing. You may receive, free of charge, any of the consumer materials by simply writing or calling the Bureau. Many of the materials are also available for viewing or downloading from the Bureau's website.