Insurance-Commissioner-Complaint-Georgia – pdf
You can file the complaint either by filling out the form and mailing it to the insurance commissioner’s office:
Georgia Insurance Commissioner’s Office
Consumer Services Division
2 Martin Luther King, Jr., Drive, Suite 716, West Tower
Atlanta, GA 30334
Or Fax to 404-657-8542
The best way to file the complaint is through the insurance commissioner’s website: https://oci.georgia.gov/file-consumer-insurance-complaint
You need to create an account.
There will be fields to fill out about your insurance company, claim number, etc…
Keep in mind, the DOI cannot decide on claims. Good Luck.
More information, courtesy of the GA DOI: https://oci.georgia.gov/file-consumer-insurance-complaint
➤ What does the Consumer Services Division of the Georgia Department of Insurance do?
The Division makes sure all insurance companies, HMOs, producers selling insurance in Georgia and other regulated entities obey state insurance laws. The Division provides consumer information and investigates complaints about companies and producers.
➤ What types of complaints the Consumer Division can handle?
We handle most insurance problems involving home, business, auto, health, HMO, life, credit, dental, etc. Those problems may include coverage issues, claim disputes, premium problems, sales misrepresentations, policy cancellations, and refunds, just to name a few. We will also investigate a complaint against a public adjuster.
➤ The Consumer Services Division cannot:
✘ Act as your lawyer or give you legal advice;
✘ Recommend an insurance company, producer or policy;
✘ Identify an insurance company with whom a particular person may have a policy;
✘ Resolve a dispute when the only evidence is your word against the word of the producer or company;
✘ Make medical judgments;
✘ Make determinations related to the facts of a case – For example, we cannot determine the value of damaged or stolen property or conclude who was at fault for an accident.
✘ Resolve complaints against service providers – including body shops, and building contractors unless the complaints involve the actions of insurers. Complaints against service providers should be directed to the appropriate licensing or enforcement agency.
➤ The Consumer Services Division does not have jurisdiction over the following plans:
■Self-insured employers and health & welfare benefit plans – Many large employers provide health benefits for their employees through self-insured plans. Although self-insured plans are frequently administered by an insurance company, it is the employer and not the insurance company that bears the risk for paying claims. Federal law exempts self-insured employer plans from state insurance regulation. The same is true of health & welfare benefit plans (union plans).
Although the Georgia Department of Insurance does not regulate self insured ERISA plans, we will provide assistance in resolving those issues if Georgia consumers request our assistance. While the Division of Insurance is willing to accept your complaint and forward it to the plan, we are not always successful in obtaining a response and we have no statutory authority to require the plan to take a specific action. We recommend you refer to your member handbook on how to file an appeal under the plan.
■Federal Employees’ health and life insurance
■Medicare HMOs
■Military Insurance
■Policies purchased in another state (HMO policies may be the exception. Call our Division for assistance if you are covered by an HMO)
■Medicare
■Medicaid
■State of Georgia Employee’s Health Plan
■University System of Georgia
➤ Consumer Services advice on helping you settle your insurance issues:
Dissatisfaction with claim settlements is the top reason consumers file complaints with the Georgia Department of Insurance. Follow these tips to help avoid claim settlement problems:
■ Read your policy carefully. It is important to know what your policy covers prior to having a loss. If you have questions about the coverages you have purchased have your Agent provide you with an explanation. You can contact our Consumer Services Division at 404-656-2070 in the Metro Atlanta Area and our toll-free number at 1-800-656-2298 if you need further explanations. Our Consumer Services Division is available by phone from 8 AM to 7PM Monday through Friday to assist you.
■ Keep copies of all correspondence between you and the insurance company. When communicating with your insurance carrier keep track of the phone numbers you called, the date and time of the call and the name and title of the individual you spoke with. After the call keep notes on what was discussed.
■ Ask the company for the specific language in the policy related to your claim. Determine whether the disagreement is because you and the insurance company interpret your policy differently. If there is a disagreement on the language in the policy you can seek assistance through the Consumer Services Division by filing a complaint and providing the documentation which will include the policy language in dispute.
■If at all possible take pictures or videos of your contents in your home and do this periodically which will help in the event of a loss. Keep the pictures or video in a safe deposit box or somewhere other than the home.
AUTO AND HOMEOWNER CLAIMS
■Keep all receipts for repairs you make to your property after damage. Auto and homeowners policies may require you to make reasonable and necessary repairs to protect your property from further damage. Your policy covers the cost of these repairs. Keep the damaged property for the claims adjuster to inspect. If possible, take photos or videos of the damage before making temporary repairs.
■Don’t make permanent repairs until the adjuster has inspected the damage.
■Ask the adjuster for an itemized explanation of the claim settlement offer. For homeowner’s claims, this should include sales tax, depreciation, and holdback depreciation for policies with replacement cost coverage. Holdback depreciation is an amount of money withheld from your claim settlement until repairs are finished or the items are replaced. Ask how the adjuster determined the estimated amount.
■Be prepared to discuss your claim if there is a disagreement on the settlement offer. The more documentation you have on items owned will make the process easier.
ACCIDENT AND HEALTH CLAIMSBe an active partner in your health insurance claim processing process. Insurance companies often need additional medical information or information from you in order to process a claim. If you get requests for information respond and keep a copy of the information sent.
■If your health insurer or health maintenance organization (HMO) refuses to pay for a recommended or ongoing treatment because the insurer or HMO determined that the treatment was not medically necessary or appropriate your health insurance policy outlines the appeal process you can follow.
■Its important when deciding on health insurance to fully understand the provisions of the policy. Although the cost may be taken into consideration, it is important to understand what the policy covers. Your agent or your employer should be able to respond to your benefit choices.
WORKERS’ COMPENSATION CLAIMS
Workers’ compensation is a state-regulated insurance program that pays your medical bills and replaces a portion of your lost wages if you are injured at work or have a work-related illness. To receive workers’ compensation benefits, your employer must have worker’s compensation insurance or self-insurance as defined by the State Board of Worker’s Compensation. The contact number is 404-656-3875. If you suffer a work-related injury or illness, you must tell your employer within 30 days of the date you were injured or became ill, or within 30 days of the date, you first knew your injury or illness might be work-related. Failure to notify your employer in a timely manner could cause you to lose your right to benefits.
➤ If you have a claim dispute, contact your insurance company first:
When contacting your insurance company, have your policy number ready. Ask where your written dispute needs to be sent. State your complaint and how you expect the company to resolve it. Sending the dispute in writing encourages a written response.
Document your phone calls by noting the phone number you called, the name of the person with whom you spoke, the date of the call and a brief summary of the conversation. Keep copies of all written communications.
In addition to the written complaint, send copies (not originals) of letters, notes, invoices, canceled checks, advertising materials, or other documents that support your complaint.
Appraisal Process for Property Insurance disputes such as Auto and Homeowner Policies: Many properties and liability policies, such as automobile and homeowners policies, provide an “appraisal” process to resolve claim disputes. In this process, you and the insurance company hire separate damage appraisers. The two appraisers choose a third appraiser to act as an “umpire.” The appraisers then review your claim and the umpire rules on any disagreements. The umpire’s decision is binding on you and the insurance company. You are required to pay for your appraiser and half of the umpire’s costs.
If you are not satisfied with the results you receive, contact the Consumer Services Division for assistance. Insurance Investigators are available to answer general questions by phone at 404-656-2070 in Metro Atlanta or our toll-free number outside of Metropolitan Atlanta at 1-800-656-2298 from 8 AM to 7 PM.
➤ Next, how to file a complaint with the Georgia Department of Insurance:
You may file a complaint with the Georgia Department of Insurance if you cannot resolve your dispute directly with your company or if you haven’t been through the appraisal process.
Our Complaint Form is located here. This form is a fillable pdf document, that can be completed, printed and submitted with copies of documents that support your complaint. This will enable us to set up a case and eliminate the need for us to request documents, and reduce the delay in providing a response. Always keep your original documents for your records.
To help ensure that The Georgia Department of Insurance receives all necessary information to investigate your complaint, include the following information with your complaint:
☑your name, address, daytime telephone number and email address
☑the exact name of the insurance company
☑the full name of any agent or adjuster who may be involved
☑your policy number
☑your claim number and the date of your loss, if applicable
☑a copy of both sides of your insurance card
☑a concise description of your problem
☑copies of all supporting documentation, including invoices, canceled checks, advertising materials, and any letters between you and the company or agent
Submit your completed form by mail at:
Georgia Department of Insurance, 2 Martin Luther King Jr. Drive, Suite 716 West Tower, Atlanta, Georgia 30334, or by fax to: (404)-657-8542.
➤ What will the Georgia Department of Insurance do to resolve your complaint?
■Send a copy of your complaint to the entity you complained against and request a detailed written response.
■Determine if your issue was handled appropriately under the terms of the policy or certificate of coverage.
■Review your file to determine if the insurance company, HMO, insurance agent, or adjuster violated state insurance laws.
■Take enforcement action when laws are violated.
Even though we may not always be able to help you resolve your complaint, your complaints and inquiries help us to assist other Georgians by identifying issues of concern and may help identify potential problems with insurance companies, HMOs, agents, or adjusters. Our involvement can also cause insurance entities to look more closely at your concerns.
➤ What happens after you file a complaint with the Georgia Department of Insurance?
■You will receive an acknowledgment letter, advising who the investigator is and their contact information. Your Case Number shown on the letter is for the issue submitted to the Department. The case number should be used to send additional information to the Department on your case.
■If you have future complaints you will get a new case number, acknowledgment letter and the new investigator’s name and contact information.
We will notify the company of your complaint and ask for a detailed response. We will send you a copy of the company’s response, with our formal letter regarding the completion of our investigation. Our review will result in one of the following actions:
▸ If the complaint has been resolved, we will send you a letter explaining the resolution.
▸ If an insurance law has been violated, we will request corrective action from the company.
▸ If the company is not abiding by the policy, we will request corrective action.
▸ If the insurer or producer has not responded to all questions or has not investigated the complaint thoroughly, we will require them to do so.
➤ What Happens if you are not satisfied with the Georgia Department of Insurance results?
If you disagree with the Department’s response to your complaint contact the Consumer Services Division and ask to speak with a Supervisor.
Please consult your telephone book for listings for attorneys and mediation services. If you need help finding an attorney, contact the State Bar of Georgia Lawyer Referral Information Service.
➤ How to avoid future complaints:
Homeowners Insurance
■Know what your policy covers and what your policy’s limits are. You may want more coverage for certain items than your policy provides. For an added premium, you can buy “endorsements” that increase coverage or provide coverage for items, not on your base policy. Some of the most common endorsements are to increase coverage for jewelry, fine arts, camera equipment, coin or stamp collections, computer equipment, and radio and television satellite dishes and antennas. Your agent can assist you with these.
■If you operate a business from home, ask your agent or company what coverages you have and what coverages you may need.
■Be fully insured. Check the limits of your homeowner’s or renter’s coverage, including contents coverage. Your current coverage may be too low to replace your personal property if you’ve made additions or new purchases or if the replacement cost has risen because of inflation. Also, some policies may only pay the actual cash value for your dwelling and contents, instead of the replacement cost.
■Review your deductibles to make sure they fit your current financial situation.
Keep records of improvements to your property.
■Maintain an inventory of personal property including furnishings, clothing, and valuables. Videotape or photograph the inside and outside of your home. Keep these photos or tapes in a safe deposit box or in a location other than your home.
■Homeowners policies do not cover damage by rising water. If you’re concerned about the possibility of flooding, consider buying flood insurance. Remember that you don’t have to live in a flood plain to suffer a flood loss. For more information about flood insurance coverage, call your insurance agent or company, or the National Flood Insurance Program administered by the Federal Emergency Management Agency, 1-800-427-4661, www.fema.gov
Automobile Insurance
■Know your policy’s coverages and coverage limits.
■Check your auto policy to see if it includes rental car reimbursement or comprehensive coverage, also called “other than collision” coverage. Comprehensive coverage pays for theft and damage resulting from causes other than accidents, such as hail and flooding. Rental car coverage pays for a replacement car while yours is being repaired because of a covered loss. It may not be available if your automobile is a total loss.
■Review your comprehensive and collision deductibles to make sure they fit your current financial situation.
■Keep records of improvements to your automobile.
Life, Accident & Health Insurance
■Read your benefit booklet to know which benefits are covered or excluded.
■Read your life insurance or annuity annual statements. Be aware of economic changes that may affect your policy’s value.
■Review your health policy or benefit plan to make sure it fits your health needs. Pay attention to restrictions, exclusions, policy limits, lifetime coverage maximums, and policy definitions.
■Determine if your policy or benefit plan covers your medical needs. For example, know whether your policy covers things such as outpatient care or day surgery. Limited benefit policies cost less but probably will not provide the benefits or services you need to meet most healthcare expenses.
■Obtain precertification for hospital admissions or provider referrals, if required.
■Understand your responsibility to notify the insurance company or HMO after being admitted to the hospital in an emergency.
■If your policy is with a preferred provider organization (PPO), be sure you understand the financial consequences of going to an out-of-network provider.
■Ask if your policy allows the health care provider to bill you for charges not paid by your health care plan.
➤ For more information or assistance:
For answers to general insurance questions or for information on filing an insurance-related complaint, call the Consumer Services Division at 404-656-2070 in Metro Atlanta or 1-800-656-2298 outside of the Metro Atlanta Area. Our phone lines are open from 8 AM to 7 PM Monday through Friday.
To report Insurance Fraud or Arson contact our Arson and Insurance Fraud Investigation at 404-656-2060.
