Fact Sheet on Filing a Complaint About Health Plans

Last Updated: November 17, 2015

Printable version of publication: Fact Sheet on Filing a Complaint About Health Plans

If you have a specific complaint about your health insurance, you should first contact your insurance company or agent for assistance. If you do not receive answers, you can complete the Office of the Commissioner of Insurance (OCI) complaint form to get an answer to your question or to file a complaint.

How to file a complaint
OCI has an online complaint form available at https://ociaccess.oci.wi.gov/complaints/public/. If you prefer to mail or fax the form instead of submitting it online, you can complete and print the complaint form and mail or fax it to:

Office of the Commissioner of Insurance
P.O. Box 7873
Madison, WI 53707-7873
Fax: (608) 264-8115

If you have questions or problems with the complaint form, call toll-free at 1-800-236-8517 (within Wisconsin) or 1-608-266-0103 (outside of Wisconsin) or send an e-mail to:

ocicomplaints@wisconsin.gov

What types of complaints does OCI handle?
OCI handles complaints involving health, life and annuity, and property and casualty insurance companies and their agents. Examples of complaints include: coverage issues, claim disputes, premium problems, sales misrepresentations, policy cancellations, and refunds. Either the enrollee or his or her representative may file a complaint.

What happens after a complaint is submitted?
A copy of your complaint will be sent to the company or agent with a request to respond directly to you and to advise our office of the action taken. You should hear from the company or agent in about 25 days from the date you send us your complaint. When we receive the information from the company or agent, we will review the file to determine what action we can take if the company or agent hasn't already resolved the complaint in your favor. We will notify you of our determination.

How is it determined that a complaint is substantiated?
OCI reviews complaints to determine if they involve a provable violation of Wisconsin insurance law. If the complaint doesn't involve a violation and you feel strongly that you have been harmed in some way, you may have to contact an attorney and pursue the matter through the courts.

What other rights do consumers have?
You have the right to a grievance hearing, during which the company's grievance committee reviews the grievance and makes a determination of whether to resolve the grievance in your favor or to uphold the company's position. You may also have the right to independent external review when the complaint involves a medical judgment. Regardless of whether the external review results in upholding or reversing the company's position, the decision is binding on both parties.

What rights do consumers have relating to network adequacy?
All health maintenance organizations (HMOs) and preferred provider organizations (PPOs) contract with physicians, clinics, hospitals and other health care providers. Some HMOs may require that you receive all services from a provider contracted with a provider network. Other HMOs and PPOs pay a higher percentage toward your claims if you receive services from a network provider versus receiving services from an out-of-network provider. HMOs and PPOs are required to have a sufficient number and type of plan providers to adequately deliver all covered services based on the demographics and health status of current and expected enrollees served by the plan. HMOs and PPOs are not required to pay for services performed by the provider of your choice who is not a network provider when the plan has in-network providers available to provide the services.