TDI Complaint Process Valerie Brown Director, Complaints Resolution Consumer Protection
Insurance Complaints An insurance complaint is “any written communication primarily expressing a grievance,” TIC Section 542.005(a) • Consumer Protection • Enforcement • Agent vs. agent • Life, Health and Licensing • Workers’ compensation networks, IROs, URAs, CHIP • Property and Casualty: • Auto and homeowners • Title • Commercial lines • Workers’ compensation classification and premium calculation
HMO Complaints • Any dissatisfaction by a complainant with the HMO’s operation, including those regarding • Plan procedures related to review or appeal of an adverse determination • Disenrollment decisions • Services provided • Denial, reduction or termination of a service for reasons not related to medical necessity • HMO complaints do not include • Misunderstandings or problems of misinformation that are resolved promptly by clearing up the misunderstanding or supplying the appropriate information to the satisfaction of the enrollee • A provider’s or enrollee’s dissatisfaction or disagreement with an adverse determination Texas Insurance Code Section 843.002(6)
DWC Complaints • Any allegation of noncompliance with the Labor Code or DWC rules • Allegations of administrative fraud • A review is completed when enforcement action is taken or when enforcement action is deemed not warranted based on facts or available evidence
Customers • Individual insurance consumers • Injured employees • Business consumers • Health care providers • Insurance carriers • HMOs • Workers’ compensation networks • Insurance agents • Attorneys • State and federal agencies • Legislators
TDI Complaints FY 2007 Complaints Resolved By Line of Coverage
2007 Provider Complaints – Top Five Reasons • Delays – claims handling • Denial of claim • Unsatisfactory settlement/offer • SB 418 rule violation • Recoupment of claims payment
TDI High-Level Complaint Processing Framework 1. Receive complaint Phone call: • If customer is a Workers’ Compensation (WC) claimant, enter appropriate information in CIS Journal • If customer wishes to file a written complaint, offer options for submitting in writing including online form, e-mail, fax, or letter Written: • Receive, sort, and deliver mail • Check for duplicate matter/existing complaint already entered in tracking database; enter new matter in tracking database • Assign appropriate codes • Create file – paper or electronic • Route to appropriate area for review and response • If correspondence involves various matters handled in different part(s) of the agency, then route copies to appropriate area(s)
TDI High-Level Complaint Processing Framework • If a complainant wishes to remain anonymous: For complaints tracked in CIS, use the “master entity ID” for an anonymous person and follow the data entry standards • If a customer who had complained more than one year ago complains to TDI again about the same matter, then create a new complaint in CIS. 2. Prioritize complaints according to nature, severity, and industry impact. Appropriately note confidential information.
TDI High-Level Complaint Processing Framework 3. Prepare response to correspondence • Read correspondence • Send acknowledgement to customer • Write to regulated entity(ies) and include copy of correspondence • Respond in 10 days per Texas Insurance Code Section 38.001 • Request extension per Commissioner’s Bulletin B-0040-00 • Review responses from regulated entity(ies) • Complete research in statutes, codes, other sources, and obtain additional information that may be needed • Draft response • Route to team leader, manager, auditor, or other role for review
TDI High-Level Complaint Processing Framework 4. Review response • Check for accuracy and completeness = were all issues addressed in response • Revise correspondence if needed • Prepare final draft of correspondence 5. Screen issues for potential referral for regulatory review • Identify “frivolous,” justified, and unjustified complaints • Check for potential enforcement or fraud referral • Check for consumer education issue
TDI High-Level Complaint Processing Framework 6. Send response to customer • Mail, fax, or e-mail response with informational/educational content • Check coding in tracking database(s), revise as needed, and close file • Copy the carrier or other entity complained about on TDI’s closing letter (as appropriate). • Average processing time is 30 days.
Complaint Data • Shopping resources for consumers • Complaint information portal page: http://www.tdi.state.tx.us/consumer/cpportal.html • Company profiles: https://apps.tdi.state.tx.us/pcci/pcci_search.jsp • Internet Complaint Information System: http://www.tdi.state.tx.us/consumer/icis/index.html • Carrier assessment of customer assistance • Stakeholder meetings (DWC/Hobby)
Complaint Referrals • Enforcement • Fraud • Market conduct