Fact Sheet on Filing a Complaint about Health Plans

Last Updated: October 16, 2018

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 may complete the Office of the Commissioner of Insurance (OCI) complaint form to file a complaint.

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
  • refunds

Either the insured individual or his or her representative may file a complaint.

Complaints are reviewed to determine whether it is probable that a Wisconsin insurance law or regulation has been violated. The complaint process cannot settle matters such as determining the value of a claim or establishing the facts surrounding a claim when there are differeng accounts of what occurred.

How to file a complaint

OCI has an online complaint form available at ociaccess.oci.wi.gov/complaints/public/. If you prefer to mail or fax the form instead of submitting it online, you may 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 (800) 236-8517 (within Wisconsin) or (608) 266-0103 (outside of Wisconsin), or send an email to:

ocicomplaints@wisconsin.gov

What happens after a complaint is submitted?

A copy of your complaint will be sent to the company or agent with a request to advise our office of the action taken and, in some instances, a request to repond directly to you with an update or attempt to resolve the matter. You should hear from the company or agent in about 20 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 has not 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 does not involve a violation and you strongly believe you have been harmed in some way, you have the option to contact an attorney and pursue the matter through the courts.

What other rights do consumers have?

You have the right to file a grievance directly with your insurance company and also to participate in the company’s grievance committee meeting. The grievance committee will review the grievance and make 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. This allows a medical expert with no connection to the health plan to review your appeal. Regardless of whether the external review results in upholding or reversing the company’s position, the decision is binding on both parties.