Resources for Legislators

Wisconsinites may file a complaint with us when they are unable to resolve a dispute with an insurance company or agent, they have a problem with a pharmacy benefit manager service, or they receive a surprise medical bill.

Some examples of complaints we can help with include coverage issues, claim disputes, billing or premium issues, sales misrepresentations, and policy cancellations. OCI regulates the insurance industry within guidelines defined in state law and regulation. We are unable to act as a lawyer or give legal advice, make medical judgements, or determine who is at fault. We cannot establish the facts surrounding a claim – including deciding which party's position is more believable. We are also unable to determine the value of a claim, the amount owed to your constituent, or act as their claim adjuster. Overall, we cannot require a company to pay a claim, refund a premium, or reinstate or issue a policy unless there is clear documentation of a confirmed violation of Wisconsin insurance law or regulation.

If our office isn't the right place to resolve your constituent's concern, we will work to make sure your constituent's complaint goes to the correct place or they are directed to the appropriate next steps such as small claims court. 

OCI's insurance examiners can help answer general insurance questions and investigate insurance complaints. We have the authority to investigate complaints related to coverage issues, claim disputes, billing or premium issues, sales misrepresentations, and policy cancellations. Here are some examples of what we may be able to help with:

• A constituent's homeowners insurance claim was denied, and they believe it should be covered under their policy.
• An insurance agent who recently sold an annuity to your elderly constituent that wasn't in their best interest and put them in a challenging financial position.
• A constituent was told they couldn't pay the cash price for a prescription drug, even though that amount would have been less than they ended up paying for their insurance copay.

Our Consumer Affairs unit has successfully recovered millions of dollars for constituents around the state when a violation of state law is identified in their case. In one 2021 case, an examiner helped a consumer obtain a refund of $43,000 in benefits for claims that had been denied. In another case, an examiner helped a consumer obtain a refund of two-years-worth of premium payments totaling nearly $3,000.

If you're not sure whether your constituent's issue is something that OCI can address, please reach out to Jeff Grothman or Sarah Smith to ask. We are happy to assist as best we can. 

Complaints related to most employer self-funded health plans, Medicare, BadgerCare, policies sold in another state or covering property in another state, and disputes with contractors are outside of our regulatory authority.

When our Legislative Affairs team receives a phone call or email regarding a constituent concern, we ask that you share as much information as possible so we can quickly evaluate the situation and respond appropriately. If you would like us to contact your constituent to answer their questions directly or open a complaint file on their behalf, we need either a phone number, email address, or mailing address.

For us to best assist your constituent, we ask that you share as much of the following information as possible:

• Constituent Name
• Constituent Phone Number
• Constituent Email Address
• Brief Description of Constituent Concern
• Constituent's Insurance Provider, if possible​
  

To initiate your constituent's complaint, we will work with the constituent to gather detailed information. As applicable, this information may include the full name and contact information for the licensed agent involved, the claim number and date of loss, and more. Once the complaint file is opened, we start the process by sending the constituent's complaint to the insurance  company and/or agent. We require the company and/or agent to respond to our office with an explanation and documentation for our review. Once we have all the relevant information from the company and/or agent, we will review the file in its entirety. During our review, our insurance examiners will determine whether the company or agent followed all Wisconsin insurance laws and the provisions of the constituent's policy. We'll work with the company or agent to try to resolve the problem. Regardless of the result, we will fully explain our determination to the constituent and your office in writing to ensure all parties know we have finished our work.