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Complaints Against Utah Health Insurance Companies

Consumer Complaints Against Commercial Health Insurance Companies

A key function of the Insurance Department is to assist consumers with questions and concerns that they have about commercial health insurance coverage. The primary agency within the Insurance Department that assists consumers with health insurance issues is the Office of Consumer Health Assistance (OCHA).

OCHA seeks to provide a variety of needed services to health care consumers and policymakers, including (but not limited to):

• Assisting consumers in understanding their contractual rights and responsibilities, statutory protections and available remedies under their health plan
• Providing health care consumer education (producing, collecting, disseminating educational materials; conducting outreach programs and other educational activities)
• Investigating and resolving complaints
• Assistance to those having difficulty accessing their health care plan because of language, disability, age, or ethnicity
• Providing information and referral to these persons as well as help with initiating a grievance process
• Analyzing and monitoring federal and state regulations that apply to health care consumers

OCHA processes more than 6,000 consumer inquires each year. These inquiries range from simple questions about how to obtain health insurance coverage to complaints against a particular health insurance company.

When a consumer inquiry involves a possible violation of the Utah Insurance Code by a commercial health insurance company, OCHA encourages consumers to file a written complaint. Once a written complaint is received, OCHA conducts an investigation and seeks to resolve the consumer complaint. OCHA tracks all written complaints made against commercial health insurers. These complaints are classified into three types: justified, question of fact, and unjustified.

Justified complaints. Justified complaints are those where the Insurance Department rules in favor of the consumer making the complaint. The Insurance Department determines that the complaint is warranted under the law and resolves the complaint by requiring the commercial health insurer to act to correct the problem.

Question of fact complaints. Question of Fact complaints are those where the complaint appears to be legitimate, but the Insurance Department was unable to make a ruling, either because there are unresolved questions about the facts of the case or because the department does not have the legal authority to do so. These complaints usually must be resolved by arbitration, mediation, or litigation.

Unjustified complaints. Unjustified complaints are those where the Insurance Department rules in favor of the commercial insurer as the insurer was judged to be acting within the bounds of the law. The Insurance Department educates consumers as to their rights under the law and how health insurance contracts work.