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Appeals & Complaints

Wisconsin residents who enroll in a health plan always have the ability to file a complaint if they are dissatisfied with their insurer or one of their agents for a legitimate reason. If you feel your carrier has violated a company policy or law, or denied a claim unjustly, you can file a complaint or claims appeal. Before doing so, it is very important to speak with your insurer about the dispute and attempt to resolve it directly with a company representative. Your health insurer also provides you the tools to file a formal appeal if your issue is regarding a denied claim, and you should always bring a complaint to their attention prior to seeking external assistance.

Of course, in the event that you have been denied coverage for a service you believed to be covered, the first place to go is your outline of benefits. Check your plan documents for any information regarding the service you received to better understand what happened. In cases where you have had other issues with your insurer, inform the company of this issue, and try to find a solution. If the attempt to straighten things out with your insurer does not go smoothly, you can contact the Office of the Commissioner of Insurance, where you can find various ways to appropriately complete a complaint form. Taking the necessary steps is essential in order to receive effective results.

 

Contact Your Health Insurance Company

Calling the member services number for your insurance company is the best way to find out how to file an appeal, and obviously the most effective way to communicate with your insurer. Find more information about appeals, claim denial, and resolving issues directly with your insurer below.

Anthem Blue Cross Blue Shield of Wisconsin

Arise Health Plan

Celtic

Dean Health Plan

Humana One

Physicians Plus   Appeal Process

Prevea360

Security Health Plan

WPS

UnitedHealthOne

 

 

Contact the Office of the Commissioner of Insurance

When you feel it necessary to resolve an issue with outside help, file a complaint with the Office of the Commissioner of Insurance in Wisconsin. You can complete a form online or if you need to attach documents or include personal information such as your date of birth or Social Security number, you may send your complaint by mail. Taking these measures, you can expect to hear from your insurer within 25 days of the date your complaint was sent to the OCI. Once you have sent your complaint to the OCI, they send a copy to your insurer, requesting they respond to you and inform the OCI that they have taken action.

After receiving information from the company or agent, the OCI reviews the files to decide what it can do, and will notify you of the conclusion they reach. They are not an attorney, though they do recommend consulting a private attorney for advice if you are not pleased with the results, or small claims court if your case had to do with a claim denial.

For any questions about the complaint forms, contact the complaints and information department at 800-236-8517 or email ocicomplaints@wisconsin.gov.

Online Complaint Form

Print Complaint Form


Recent Wisconsin Health Insurance Complaints

The most recent report on health insurance company complaints and administrative actions processed through the Office of the Commissioner of Insurance available is for the year 2010. There were 3,212 total complaints in 2010 for accident and health insurance policies, far outnumbering any other type of coverage. The list was comprised of companies with a premium volume of at least $1 million, or at least 5 complaints in 2010. Therefore, the report did not highlight the majority of individual insurers in Wisconsin. The Wisconsin average is .03 complaints per $100,000 of written premiums. For health insurers, WPS had the highest ratio of complaints to premiums at 0.18 and 5 complaints. [Anthem] Blue Cross Blue Shield of Wisconsin had a much lower ratio at 0.05 with 74 complaints, and a much higher membership than WPS in 2010.

View the full 2010 insurance report: Complaints & Administrative Actions

According to the National Association of Insurance Commissioners (NAIC), the following companies have reported numerous complaints in 2012. The table below features the current number of complaints for each company as of 12/12/12. It is clearly advisable to stay away from Humana, as they not only have the highest premiums in every city but the most complaints. Anthem Blue Cross Blue Shield is doing much better than in 2010, with 45 complaints this year.

To find more company information for this and previous years, search the NAIC Consumer Information Source.

 

 

 

 

 

 

Sources:

 

1. Wisconsin Office of the Commissioner of Insurance. “Insurance Complaint Form.” http://oci.wi.gov/com_form.htm.

2. April 2011. Wisconsin Office of the Commissioner of Insurance. ” 2010 Insurance Complaints and Administrative Actions.” PI-030.

3. National Association of Insurance Commissioners. “NAIC Consumer Information Source.” https://eapps.naic.org/cis/.

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