Merritt Personal Lines Manual: Disputing Decisions

Unlike HMOs (which usually have to respond within six months), traditional indemnity plans are not required to respond to the insured's complaints within a set time frame or have provisions for a formal hearing or appeals process. But if the insured is not satisfied with the insured's insurer's willingness to pay a claim, the insured can ask for a reconsideration of the decision.

If the insured has problems getting reimbursed, an indemnity plan allows the insured to choose the insured's method of recourse, i.e., the court system or mediation. In addition, the insured has the option to appeal any decision by the insurance company to pay or deny a claim.

The insured can also file a complaint with the state's Department of Insurance and the insured doesn't have to tell the insurance company first. The insured will have to fill out a complaint form and supply any information needed to support the insured's position to the Department.

Department investigators will usually then contact the insurance company; and, if the problem cannot be resolved within about 10 days, they will investigate whether the insurance company followed the terms of the insured's policy.