TDI Complaint Process

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TDI Complaint Process

• Valerie Brown
• Director, Complaints Resolution
• Consumer Protection

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Insurance Complaints

• An insurance complaint is any written
  communication primarily expressing a grievance,
  TIC Section 542.005(a)
• Consumer Protection
• Enforcement
• Agent vs. agent
• Life, Health and Licensing
• Workers compensation networks, IROs, URAs, CHIP
• Property and Casualty
• Auto and homeowners
• Title
• Commercial lines
• Workers compensation classification and premium
  calculation

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HMO Complaints

• Any dissatisfaction by a complainant with the
  HMOs operation, including those regarding
• Plan procedures related to review or appeal of an
  adverse determination
• Disenrollment decisions
• Services provided
• Denial, reduction or termination of a service for
  reasons not related to medical necessity
• HMO complaints do not include
• Misunderstandings or problems of misinformation
  that are resolved promptly by clearing up the
  misunderstanding or supplying the appropriate
  information to the satisfaction of the enrollee
• A providers or enrollees dissatisfaction or
  disagreement with an adverse determination
• Texas Insurance Code Section 843.002(6)

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DWC Complaints

• Any allegation of noncompliance with the Labor
  Code or DWC rules
• Allegations of administrative fraud
• A review is completed when enforcement action is
  taken or when enforcement action is deemed not
  warranted based on facts or available evidence

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Customers

• Individual insurance consumers
• Injured employees
• Business consumers
• Health care providers
• Insurance carriers
• HMOs
• Workers compensation networks
• Insurance agents
• Attorneys
• State and federal agencies
• Legislators

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TDI ComplaintsFY 2007 Complaints Resolved
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TDI Complaints FY 2007 Complaints Resolved By
Line of Coverage
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2007 Provider Complaints Top Five Reasons

• Delays claims handling
• Denial of claim
• Unsatisfactory settlement/offer
• SB 418 rule violation
• Recoupment of claims payment

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TDI High-Level Complaint Processing Framework

• 1. Receive complaint
• Phone call
• If customer is a Workers Compensation (WC)
  claimant, enter appropriate information in CIS
  Journal
• If customer wishes to file a written complaint,
  offer options for submitting in writing including
  online form, e-mail, fax, or letter
• Written
• Receive, sort, and deliver mail
• Check for duplicate matter/existing complaint
  already entered in tracking database enter new
  matter in tracking database
• Assign appropriate codes
• Create file paper or electronic
• Route to appropriate area for review and response
• If correspondence involves various matters
  handled in different part(s) of the agency, then
  route copies to appropriate area(s)

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TDI High-Level Complaint Processing Framework

• If a complainant wishes to remain anonymous
• For complaints tracked in CIS, use the master
  entity ID for an anonymous person and follow the
  data entry standards
• If a customer who had complained more than one
  year ago complains to TDI again about the same
  matter, then create a new complaint in CIS.
• 2. Prioritize complaints according to nature,
  severity, and industry impact. Appropriately
  note confidential information.

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TDI High-Level Complaint Processing Framework

• 3. Prepare response to correspondence
• Read correspondence
• Send acknowledgement to customer
• Write to regulated entity(ies) and include copy
  of correspondence
• Respond in 10 days per Texas Insurance Code
  Section 38.001
• Request extension per Commissioners Bulletin
• B-0040-00
• Review responses from regulated entity(ies)
• Complete research in statutes, codes, other
  sources, and obtain additional information that
  may be needed
• Draft response
• Route to team leader, manager, auditor, or other
  role for review

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TDI High-Level Complaint Processing Framework

• 4. Review response
• Check for accuracy and completeness were all
  issues addressed in response
• Revise correspondence if needed
• Prepare final draft of correspondence
• 5. Screen issues for potential referral for
  regulatory review
• Identify frivolous, justified, and unjustified
  complaints
• Check for potential enforcement or fraud referral
• Check for consumer education issue

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TDI High-Level Complaint Processing Framework

• 6. Send response to customer
• Mail, fax, or e-mail response with
  informational/educational content
• Check coding in tracking database(s), revise as
  needed, and close file
• Copy the carrier or other entity complained about
  on TDIs closing letter (as appropriate).
• Average processing time is 30 days.

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Complaint Data

• Shopping resources for consumers
• Complaint information portal page
  http//www.tdi.state.tx.us/consumer/cpportal.html
• Company profiles https//apps.tdi.state.tx.us/pcc
  i/pcci_search.jsp
• Internet Complaint Information System
  http//www.tdi.state.tx.us/consumer/icis/index.htm
  l
• Carrier assessment of customer assistance
• Stakeholder meetings (DWC/Hobby)

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Complaint Referrals

• Enforcement
• Fraud
• Market conduct