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Insurance Not Paying? cont...

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Texas' prompt-payment law requires licensed insurance companies and HMOs to acknowledge claims, begin investigations and request any needed information within 15 days after receiving a claim. Surplus lines carriers have 30 days to complete this process. A surplus lines carrier is an out-of-state company not licensed in Texas but allowed to insure hard-to-place risks. Notify you in writing of the acceptance or rejection of your claim within 15 business days after receiving all required information. This deadline may be extended an additional 15 days in the event of a "declared" weather-related or natural disaster. If the company cannot accept or reject your claim within the time limit, the company must tell you why it needs more time to process your complaint. The company will then have up to 45 additional days after this notice to accept or reject your claim. Give the reason in writing for rejecting your claim. Make payment within five business days after notifying you that your claim will be paid. Surplus lines carriers must pay your claim within 20 business days. If you win a lawsuit for the violation of the prompt-payment law, the court can require the company to pay your attorney fees and a monetary penalty.

If you cannot resolve your dispute directly with your company, you may file a complaint with TDI. A complaint form is available at TDI's Web site (www.TDI.state. You can print out the form or submit it online. You also may obtain complaint forms by calling 1-800-599-SHOP (7467). In Austin, call 305-7211. Mail or fax your complaint along with copies of documentation to: Texas Department of Insurance Consumer Protection Program (111-1A) P.O.Box 149091 Austin, TX 78714-9091 FAX 512-475-1771. To help ensure that TDI receives all necessary information to investigate your complaint, include the following with your complaint: your name, address and daytime telephone number the exact name of the insurance company the full name of any agent or adjuster who may be involved your policy number your claim number and the date of your loss, if applicable. a concise description of your problem what you believe would be a fair resolution of your complaint Copies of all supporting documentation, including invoices, canceled checks, advertising materials, and any letters between you and the company or agent.

TDI accepts and investigates complaints against insurance companies, HMOs, insurance agents, adjusters, and fully insured or fully funded health benefit plans. Health plans purchased by an employer from an insurance company or HMO are called fully insured or fully funded health benefit plans. Types of complaints investigated include disputes about claims and benefits, false advertising, misrepresentation, and suspected insurance fraud.

If your dispute involves workers compensation claims, call the Texas Workers' Compensation Commission at 1-800-252-7031. TDI may not be able to resolve your complaint, but our involvement typically causes insurers to look more thoroughly at your concern. In addition, your complaints and inquiries help us to assist other Texans by identifying insurance companies, HMOs, and agents that should be investigated and determining what issues consumers need help with.

Important! Many employers have self-funded health benefit plans that are regulated by federal law. This means your employer may set aside funds and employee contributions each month to pay health coverage claims submitted by plan participants. A self-funded plan may hire an insurance company, HMO, or third-party administrator to coordinate providers and handle claims and paperwork, but the employer assumes the insurance risk. Federal law prohibits the states from regulating valid self-funded plans or the third-party administrators that administer those plans. These plans come under the jurisdiction of the U.S. Department of Labor.

Certain other group health plans maintained by governments, churches, some school districts, and out-of-state Blue Cross organizations also are exempt from most state insurance regulations, but may be regulated by local governments.

To limit potential problems, especially with a valid self-funded plan, you should, verify whether the plan is fully insured or self-funded. It may not be obvious. Read your benefit booklet carefully. Understand what is and is not covered. Follow all procedures and deadlines for seeking medical treatment and filing claims, complaints, and appeals. Take complaints and appeals to the person or office authorized in your benefits booklet and other plan documents. If the plan is fully insured, take any unresolved complaints to TDI. If the plan is self-funded and offered by a private sector employer or bona fide union, take unresolved complaints to the Dallas office of the U.S. Department of Labor's Pension and Welfare Benefits Administration. Call 214-767-6831. If the plan is self-funded but offered through a government or church employer, follow the appeals procedures in your benefits booklet and other plan documents. In most cases, ultimate responsibility for resolving disputes rests with the governing body of the employer sponsoring the plan, such as a school board or commissioners' court.

You may wish to consult an attorney to discuss your concerns. More Texans are asking their company to use Alternative Dispute Resolution (ADR) to settle their complaints. ADR generally refers to the use of a neutral third party to help settle a dispute outside a formal court of law. ADR may be done with or without an attorney's representation. Use of ADR to settle your insurance claim can avoid the delays and costs of a trial. If you use ADR, you do not surrender your right to insist on full and fair compensation. In most cases, ADR also does not eliminate your ability to sue or go to trial. You do not need an attorney to use ADR, although you may hire one if you wish. Please consult your telephone book for attorney referral listings, information services, and mediation organizations or call the State Bar of Texas at 1-800-204-2222. In Austin, call 463-1463.

Consumer Help Line (8 a.m. to 5 p.m. CST)
1-800-252-3439 - In Austin, call 463-6515
Publications/Complaint Form (24 hours)
Order Line: 1-800-599-SHOP (7467)
Austin, call 305-7211
WOSG-modem: 1-800-227-8392 Austin, call 475-1051

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