tdi advice on insurance claims and complaints

8/6/2019 TDI Advice on Insurance Claims and Complaints

1/5

Appraisal ProcessMost automobile and homeowners policies allow you to resolve claim disputes through an appraisal

process. You can use the appraisal to negotiate with the company, or to appeal or take the matter tocourt. Ask your company if your policy allows an appraisal.

In the appraisal process, you and the insurance company hire separate damage appraisers. The twoappraisers choose a third appraiser to act as an umpire. The appraisers review your claim, and theumpire rules on any disagreements. You are required to pay for your appraiser and half of the umpire'scosts.

You and the insurance company must accept the umpires decision about the loss amount. If there is adispute over what is covered, you can ask the company to reconsider the coverage issue.

TDIs Complaint ProcessYou may complain to us if you cannot resolve your dispute directly with your company and you haven't

been through the appraisal process.To file an insurance complaint online, visit our website. You may also e-mail, mail, or fax thecomplaint form, along with copies of your supporting documents, to

Texas Department of InsuranceConsumer Protection Program (MC 111-1A)P.O. Box 149091Austin, TX 78714-9091Fax: 512-475-1771E-mail: [email protected]

If you have a complaint against an HMO, mail or fax your complaint along with copies of your supporting documents to

Texas Department of InsuranceHMO Quality Assurance Section (MC 103-6A)P.O. Box 149091Austin, TX 78714-9091Fax: 512-322-4260

If your dispute involves a workers compensation claim, call the Injured Worker Hot Line or your local Division of Workers' Compensation field office. The field office will tell you how you can schedule a benefit review conference to help resolve your dispute.

1-800-252-7031

We need the following information to investigate your complaint: your name, address, and daytime telephone number the exact name of the insurance company the name of agents or adjusters involved your policy number your claim number and the date of your loss, if applicable
mailto:[email protected]:[email protected]


2/5

a copy of both sides of your insurance card a 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.

After you send your complaint to us, we will: Send you an acknowledgment letter with the name and phone number of the complaint

specialist assigned to your complaint. Notify the company about your complaint and ask for a detailed response. Send you a copy of the companys response and an explanation of the outcome, usually within

45 days after we receive your complaint. Determine if your issue was handled appropriately and within the terms of the policy or

certificate of coverage. Determine if the company, agent, or adjuster broke state insurance laws, and take enforcement

action when laws are broken.

While we make every effort to help you resolve your complaint, we cannot: Make determinations about negligence or fault in an accident. These types of disputes must be

resolved in court. Resolve a dispute between you and the insurance company when the only evidence is your

word. Force a company to pay a disputed claim or make an exception to the contract if no insurance

laws have been violated. Give legal advice or make medical judgments.

Even if we cant resolve your complaint, your complaints and inquiries help us identify issues and potential problems with insurance companies, HMOs, agents, or adjusters. Our involvement can also

cause companies to look more closely at your concerns.If youre not satisfied with the results, you can discuss your concerns with an attorney. You may alsorequest alternative dispute resolution (ADR) to settle problems with your insurance company. ADR uses techniques such as mediation with a neutral third party to settle disputes outside court.

Look in your telephone book for attorneys and mediation services. If you need help finding an attorney,call the State Bar of Texas Lawyer Referral Information Service

1-800-252-9690www.texasbar.com

Before You File a ComplaintIf you have a complaint, contact your company first. Many complaints can be resolved without our intervention by contacting the company and talking to them about your issue.

We require most insurance companies in Texas to have a toll-free telephone number for customer assistance. The toll-free number should be listed on your policy. You may also get the number bycalling our Consumer Help Line or using the Check Companies feature on our website

1-800-252-3439
http://www.texasbar.com/https://apps.tdi.state.tx.us/pcci/pcci_search.jsphttp://www.texasbar.com/https://apps.tdi.state.tx.us/pcci/pcci_search.jsp


3/5

463-6515 in Austinwww.tdi.state.tx.us

When you call your company: Have your policy number ready. Ask for a written response to your complaint. Follow up in writing. Describe your complaint and how you expect the company to resolve it. Send copies (not originals) of letters, notes, invoices, canceled checks, advertising materials, or

other documents that support your complaint.

Be Claim SmartMost of the complaints we deal with involve disputes over claim settlements. Follow these tips to helpavoid claim settlement problems:

Read your policy carefully. A policy is a contract between you and the insurance company.Don't rely solely on your agent to tell you what your policy covers. Read the Consumer Bill of Rights. Insurance companies must include it with personal

automobile, homeowners, and credit life policies or renewals. It explains your rights andresponsibilities. For a copy, call your insurance company or visit our website.

Keep copies of all documents and take notes about all calls between you and the insurancecompany. Include the date and subject of any conversations you have and the name and title of the person you spoke to.

Ask the company for the specific language in the policy related to your claim. Determinewhether the disagreement is because you and the insurance company read your policydifferently.

Auto and Homeowner Claim Tips Keep all receipts for repairs you make after your property is damaged. Auto and homeowners

policies may require you to make reasonable and necessary repairs to prevent further damage.Your policy covers the cost of these repairs. If possible, take photos or videos of the damage

before making temporary repairs. Don't make permanent repairs until the adjuster has inspected the damage. Keep the damaged

property for the claims adjuster to inspect. Ask the adjuster for an itemized explanation of theclaim settlement offer. For homeowners claims, this should include sales tax, depreciation, andholdback depreciation for policies with replacement cost coverage. Holdback depreciation is themoney your company wont pay until repairs are finished or the items are replaced. Ask theadjuster how they get this number.

Be prepared to negotiate to get a fair settlement. Don't be shy about to negotiating with thecompany for a better offer.
http://www.tdi.state.tx.us/index.htmlhttp://www.tdi.state.tx.us/index.html


4/5

Deadlines for Payment of a ClaimTexas law requires insurance companies to pay first-party claims promptly. A first-party claim is oneyou file against your insurance company. Texas' prompt-payment law requires licensed insurancecompanies to

Acknowledge claims, begin investigations, and request information within 15 days after receiving a claim. Surplus lines carriers have 30 days to complete this process. (A surplus linescarrier is an out-of-state company not licensed in Texas but eligible to insure hard-to-placerisks.)

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 theevent of a declared weather-related or natural disaster.

If the company cannot accept or reject your claim within the time limit, the company must tellyou why it needs more time. The company will then have up to 45 additional days after thisnotice 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 after notifying you that itwill be paid.

Prompt-payment laws do not apply to liability insurance claims against another person'sinsurance company or claims involving:

self-funded health plans workers' compensation mortgage guaranty or title insurance fidelity, surety, or guaranty bonds marine insurance (other than inland marine)

How to Avoid Future Complaints

Homeowners, Renters, and Condo Insurance Know what your policy covers and what the limits are. You may want more coverage for certain

items than your policy provides. For an added premium, you can buy endorsements thatincrease coverage or provide coverage for items not on your base policy. Some of the mostcommon endorsements add replacement cost coverage and increase coverage for jewelry, fine

arts, camera equipment, and computer equipment. If you operate a business from home, ask your agent or company what coverages you have and

what coverages you may need. Make sure your coverage fits your needs. Check the limits of your coverage, including contents

coverage. Your current coverage may be too low to replace your personal property if you'vemade additions or new purchases or if the replacement cost has risen because of inflation. Also,some policies may only pay actual cash value for your dwelling and contents, instead of thereplacement cost.

Review your deductibles to make sure they fit your current financial situation.


5/5

Keep records of improvements to your property. Maintain an inventory of personal property including furnishings, clothing, and valuables.

Videotape or photograph the inside and outside of your home. Keep these photos or tapes in asafe deposit box or in a location other than your home.

Homeowners policies do not cover damage by rising water. If you're concerned about the possibility of flooding, consider buying flood insurance. Remember that you don't have to live

in a flood plain to suffer a flood loss. For more information about flood insurance coverage, callyour insurance agent or company, or the National Flood Insurance Program administered by theFederal Emergency Management Agency (FEMA) at 1-800-427-4661 or visit them online atwww.fema.gov .
http://www.fema.gov/http://www.fema.gov/http://www.fema.gov/

tdi advice on insurance claims and complaints

Documents