Understanding the Consumer Complaint Process Revised September 2005

What does the Illinois Division of Insurance do?

The Division of Insurance makes sure all insurance companies, HMOs, producers selling insurance in Illinois and other regulated entities obey state insurance laws. The Division provides consumer information and investigates complaints about companies and producers.

What types of complaints does the Division handle?

We handle most insurance problems involving home, business, auto, health, HMO, life, credit, dental, etc. Those problems may include coverage issues, claim disputes, premium problems, sales misrepresentations, policy cancellations, and refunds, just to name a few. We will also investigate a complaint against a public adjuster. Please follow the "How to file a complaint" steps if you want to file a complaint against a public adjuster.

The Division cannot:

• Act as your lawyer or give you legal advice;
• Recommend an insurance company, producer or policy;
• Identify an insurance company with whom a particular person may have a policy;
• Resolve a dispute when the only evidence is your word against the word of the producer or company;
• Make medical judgments;
• Make determinations related to the facts of a case – For example, we cannot determine the value of damaged or stolen property or conclude who was at fault for an accident.

The Illinois Division of Insurance does not have jurisdiction over the following plans:

1. Self-insured employers and health & welfare benefit plans – Many large employers provide health benefits for their employees through self-insured plans. Although self-insured plans are frequently administered by an insurance company, it is the employer and not the insurance company that bears the risk for paying claims. Federal law exempts self-insured employer plans from state insurance regulation. The same is true of health & welfare benefit plans (union plans). While the Division of Insurance is willing to accept your complaint and forward it to the plan, we are not always successful in obtaining a response and we have no statutory authority to intervene or require the plan to take specific action. We recommend you refer to your member handbook on how to file an appeal under the plan. The U.S. Department of Labor has some oversight of these plans.
2. Federal Employees' health and life insurance
3. Medicare HMOs
4. Military Insurance
5. Policies purchased in another state (HMO policies may be the exception. Call our Division for assistance if you are covered by an HMO)
6. Medicare
7. Medicaid
8. KidCare
9. Illinois Comprehensive Health Insurance Plan
10. State of Illinois Employee Quality Care Plan

For information on how to file complaints regarding the above plans, see our Fact Sheet entitled, Contact the Proper Agency - Where To File Medicare, Medicaid and Other Health Plan Complaints on our website at www.idfpr.com/DOI/default2.asp or call our Consumer Assistance Hotline toll-free number (866) 445 -5364.

Before filing a complaint:

1. Contact the insurance company or agent and bring the problem to their attention. Document your phone calls by noting the name of the person you speak to, the date of the call and a brief summary of the conversation. Keep copies of all written communications.

2. If you are not satisfied with the results you receive, contact the Division of Insurance for assistance. Insurance analysts are available to answer general questions by phone at our toll-free Consumer Assistance Hotline (866) 445-5364. However, complaints must be submitted in writing.

How to file a complaint

1. Complaints may be submitted in the following ways:

• On-line at www.idfpr.com/DOI/default2.asp (Click on Consumer/Provider link at left of page)
• By email at consumer_complaints@ins.state.il.us.
• By fax to (217) 558-2083.
• By mail to 320 W. Washington Street , Springfield , IL 62767

Keep your originals and send only copies of information. For a printed copy of our Division's complaint form, contact our toll-free Consumer Assistance Hotline at (866) 445-5364.

2. When we receive your complaint, we will assign a file number and send you written notification of that number. Please refer to the complaint file number when you call or write to us.
   
3. When we receive a response from the company or producer, we will review the complaint and response. Our review will result in one of the following actions:
   • If the complaint has been resolved, we will close the file and send you a letter;
   • If an insurance law has been violated, we will request corrective action;
   • If the company is not abiding by the policy, we will request corrective action;
   • If the insurer or producer has not responded to all questions or has not investigated the complaint thoroughly, we will require them to do so;
   • If no violation of Illinois insurance law is found, we will send you a letter explaining why the investigation is being closed.

In each instance, you will receive a written response from our Division explaining the results of our investigation.

Illinois Department of Financial and Professional Regulation

Division of Insurance
320 W. Washington Street
Springfield , IL 62767
(866) 445-5364 toll free
(217) 558-1083 fax
www.idfpr.com

I Want to File a Complaint