Last Updated: January 21, 2022
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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
file a complaint with the Office of the Commissioner of Insurance (OCI).
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:
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 differing accounts of what occurred.
How to file a complaint
OCI has an online complaint form available at
oci.wi.gov/Complaints. 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: email@example.com
There is a separate form for complaints related to the No Surprises Act.
What happens after a complaint is submitted?
We will send a copy of your complaint to the company or agent with a request to advise our office of the action taken and, in some instances, a request to respond directly to you with an update or attempt to resolve the matter.
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, 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 to participate in the company’s grievance committee meeting. The grievance committee will review the grievance and decide whether to resolve the grievance in your favor or to uphold the company’s position.
You 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. Learn more about the Independent Review Process.