Before You File an Insurance Complaint
Types of Complaints the DISB’s Consumer Division Can Handle
We handle most insurance problems involving home, business, auto, health, HMO, life, dental, etc. Those problems may include coverage issues, claim disputes, premium problems, sales misrepresentations, policy cancellations, and refunds. We will also investigate complaints against insurance producer/brokers and public adjuster. It takes approximately 45 days for investigation and resolution of a complaint.
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 property 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 us at the Consumer Services Division for assistance. Insurance Operations Specialists are available to answer general questions by phone at (202) 727-8000 from 8:15 am to 4:45 pm.
What DISB cannot do:
- Assume the role as your legal representative, in or out of court.
- Intervene in a pending lawsuit or case where you are represented by legal counsel, or execute a judgment.
- Make a medical decision as to the extent of an individual’s medical condition although we can investigate to determine (1) if the denial is arbitrary or capricious and (2) whether or not the denial decision was rendered in accordance with the terms of the insurance contract and DC Insurance laws and regulations.
Decide disputes between policyholders or claimants and insurance companies (or their representatives) that involve the following and similar matters:
- Who is negligent or at fault
- The facts surrounding a claim (that is, who might be telling the truth in the matter when accounts of that matter differ);
- The value of a claim or the amount of money owed to you; or
- Any other factual disagreements between you and any other party.
- Identify an insurance company with whom a particular person may have a policy;
- 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 DISB does not regulate self insured ERISA (Employee Retirement Income Security Act) plans, we will provide assistance in resolving those issues if a District of Columbia consumer request our assistance. While the Consumer Services Division 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 specific action. We recommend you refer to your member handbook on how to file an appeal under the plan.
- Federal Employees' Program ( Health and life insurance)
- Medicare HMOs
- Uniform Services Family Insurance Plans
- Policies purchased in another state (Certain health policies may be an exception. Call DISB for assistance if you are covered by an affinity group plan)
- Workers’ Compensation
- DC Healthcare Alliance
- DC Healthy Families
Consumer Services advice on helping you settle your insurance issues:
Dissatisfaction with claim settlements is the top reason consumers file complaints with DISB. 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 or obtaining medical services. If you have questions on the coverages you have purchased have your Agent provide you an explanation. You can contact our Consumer Services Division at 202-727-8000 if you need further explanations. Our Consumer Services Division is available by phone from 8 am to 6 pm - 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.
- Statues of limitations apply to all lines of insurance claims.
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 homeowners’ 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 estimate 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 Claims
- Be an active partner in you 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 in a timely manner 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.
- It’s important when deciding on health insurance to fully understand the provisions of the policy. Although cost may be taken into consideration, it’s 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 District of Columbia’s Office of Worker’s Compensation. Contact number is 202-727-1000.
- 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.
What happens if you are not satisfied with DISB’s results?
If you disagree with the Department’s response to your complaint contact the Consumer Services Division and ask to speak with a Supervisor.
You may wish to consult an attorney to discuss your concerns. You may also request alternative dispute resolution (ADR) to settle disputes with your insurance company on property claims. ADR uses techniques such as mediation with a neutral third party to help settle a dispute outside a formal court of law.
Please consult your telephone book for listings for attorneys and mediation services. If you need help finding an attorney, contact the DC Bar Association for Lawyer Referral Information Services.
How to avoid future disputes:
- 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 homeowners or renters 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 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.
- 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 and 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 health care expenses.
- Obtain pre-certification for hospital admissions or provider referrals, if required.
- Determine eligibility and waiting periods for benefits under pre-existing conditions.
- 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.