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State insurance department complaints: what they can and cannot do

Every state has a department that takes consumer complaints about insurers, agents and claims handling. It is free. It is not a lawsuit and not an appeal, and it may not change the result in every case.

What departments generally do

• Investigate complaints about unfair claim delays or denials, failure to honor a policy, violations of state insurance law, lack of timely communication and unjustified cancellation or nonrenewal.
• Forward your complaint to the insurer, which must respond. If they find a violation, they can require the insurer to correct the problem and follow state law.
• Some also run or oversee state external review of health denials.

Limits (from regulators' own pages)

• They generally cannot make an insurer pay unless a law or the policy was violated, cannot decide disputes where the facts are disputed, and do not act as your lawyer or give legal advice.
• Self-funded employer plans are usually outside state jurisdiction (see ERISA vs state-regulated plans).
• Filing a complaint does not stop deadlines. Arizona's department says so explicitly. Keep appealing on time.
• Complaints may become public record in some states; the page for your state says. Think about what you attach.

Before you file

1. Try the insurer first and keep a log of dates, names and what was said.
2. Gather the denial letter, your appeal and the response, policy pages and bills.
3. Write a factual timeline; skip personal commentary; say what outcome you want.

Use the state directory to find your department's complaint page, and the complaint summary letter to organize your answers.