Fillable Michigan form FIS-0030 - Insurance Complaint

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Michigan form FIS-0030 - Insurance Complaint

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The Michigan form FIS-0030 - Insurance Complaint form is 4 pages long and contains:

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Other Sources:
Workers’ Compensation Claims:
Department of Licensing and Regulatory Affairs
Workers’ Compensation Agency
P.O. Box 30016
Lansing, MI 48909
888-396-5041
www.michigan.gov/wca
Complaints Against a Residential
Builder or Building Contractor:
Department of Licensing and Regulatory Affairs
Bureau of Professional Licensing
P.O. Box 30018
Lansing, MI 48909
517-373-8068
www.michigan.gov/bpl
Complaints Against Automobile Repair
Facilities or Vehicle Dealer:
Michigan Department of State
Regulatory Monitoring Division
Bureau of Information Security (BIS)
1-888-SOS-MICH (1-888-767-6424)
www.michigan.gov/sos
Complaints Concerning Warranties:
Attorney General
Consumer Protection Division
P.O. Box 30213
Lansing, MI 48909
1-877-765-8388
www.michigan.gov/ag
Guide to Resolving
Insurance Problems
Department of Insurance and Financial Services
Ofce of Consumer Services
P.O. Box 30220
Lansing, MI 48909-7720
Michigan Department of Insurance and Financial Services
DIFS is an equal opportunity employer/program.
Auxiliary aids, services and other reasonable accommodations are available upon
request to the individuals with disabilities.
Visit DIFS online at: www.michigan.gov/DIFS or call DIFS toll-free at 877-999-6442
When You Have a Dispute With
an Insurer or Agent:
Use the attached form to le a
complaint with the Department of
Insurance and Financial Services
(DIFS) if you are in a dispute with an
insurer and/or agent. This brochure
outlines DIFS complaint process,
offers ways to resolve your dispute,
and explains how DIFS can help.
If your complaint involves a dispute
regarding your health coverage,
please refer to the Health Insurance
Complaint Form and brochure.
First Contact the Company or
Agent:
If you disagree with an insurance
company or insurance agent in
Michigan, rst contact the company
and/or agent directly.
•Speak with a company representative
to try to nd a solution.
•Explain the problem in a calm,
courteous manner.
•Provide dates, amounts, and as many
related facts as you can.
If you still do not agree with the
company’s position, ask them to
provide a written response. Ask them
to list the specic rules or language in
the policy that allow them to deny or
exclude coverage.
If you feel that your insurance agent
misrepresented what your policy covers,
made false statements to persuade your
decision about coverage, or used other
fraudulent methods, try to resolve the
dispute by speaking directly with the
agent.
If you still do not agree with the agent’s
position, ask for a written response. Ask
the agent to include policy language,
copies of documents you signed when
you applied for insurance, or other
reasons or facts, which might support the
agent’s actions.
How DIFS Can Help:
If you are still dissatised after contacting
the company or the agent, you may wish
to contact DIFS, Ofce of Consumer
Services, to ask questions or to le a
written complaint.
When you le a complaint, Consumer
Services acts as a link between you and
the company or agent. We try to resolve
the complaint and see that your questions
are answered. Your complaint is based
on the documents you submit. Be sure to
include all pertinent information. Include:
•Name of the insurer and/or agent
involved in the dispute.
•Policy and claim numbers.
•Details of any previous contact regarding
the matter.
•Copies of documents that help verify or
explain the problem.
Always send copies. Please do not
send original documents.
When we receive your complaint, we
will open a le and send you a letter
detailing the complaint process. This
letter will include a le number that
should be referenced on any future
correspondence or calls to our ofce
relating to this matter.
We will contact the parties named in
the complaint and send them an exact
copy of your complaint letter. We ask
them to review the matter and provide
us with a written response. We then
review the response to determine if it:
•Complies with the policy language.
•Complies with Michigan insurance
laws, rules, or directives of the
Director.
•Addresses the issues in your
complaint and is reasonable in light
of approved and accepted business
practices.
When our review is complete, we will
provide you with a response detailing
our ndings and explain the reason
for the outcome pursuant to the policy
language and pertinent laws.
If you have questions, disagree
with our ndings, or have additional
information that was not included
with your original complaint, and feel
it might alter the decision, you may
contact us or submit the information
to us for further review.
Please understand that we strive to
resolve all complaints. We may not
be able to provide the exact results
you desire, as we can only resolve
disputes based on the information
provided and our authority under
Michigan law. However, we hope
through our complaint process you
are able to gain an understanding of
the situation and the policy language
and laws that apply.
While we strive to give prompt, quality
service, a resolution may not occur
immediately. We may need to contact
you, the insurer, or agent multiple
times, depending on the case.
Thank you for your patience during
the complaint process.
What DIFS Cannot Do:
Our authority is limited to the
companies and agents DIFS licenses.
We cannot help resolve disputes with
entities we do not license. Helpful
contact information is included at the
end of this brochure.
Because DIFS regulates the business
of insurance transacted in Michigan,
our authority pertains to contracts
issued in Michigan. If your policy was
issued in another state, please contact
that state’s insurance department.
DIFS has no authority over third party
liability claims. We are unable to force
insurers to pay these types of claims.
We also cannot decide questions of fact,
but we may be able to refer you to the
appropriate authority to seek further help.
Provider Complaints:
DIFS generally only accepts complaints
from parties involved in the contract, such
as the insured, policyholder or certicate
holder. Because a health care provider is
not a party to the health care contract, we
generally do not accept complaints from
providers.
DIFS will pursue complaints from
providers acting as the authorized
representative of a patient covered by a
Michigan licensed health carrier or no-
fault automobile insurer. However, written
authorization from the patient or their
legal representative must be included
with the complaint.
Providers occasionally have problems
with receiving timely payment for
submitted claims without any errors or
other issues, often referred to as “clean
claims.” Public Act 316 of 2002 was
enacted to afford provisions in handling
untimely clean claim payments.
A health professional, health facility, home
health care provider, durable medical
It is DIFS’ duty to sustain an active
relationship with Michigan’s consumers.
equipment provider, or health plan
alleging that a timely processing or
payment procedure has been violated
may le a clean claim complaint with
DIFS on Form FIS 0284 and has a
right to a determination of the matter
by the Director or his or her designee.
Information regarding this process and
the form are available on the DIFS
website at www.michigan.gov/difs.
Michigan law, including PA 218 of 1956 as amended, authorizes the review of
consumer complaints involving insurance and similar products. Completion of this
form is voluntary and helps us review your complaint.
FIS 0030 (11/17) Department of Insurance and Financial Services
Insurance Complaint Form
Please list events in the order they happened. Attach additional pages if needed. If possible please use letter size paper (8 ½ x 11”) for all attachments.
Details of my complaint:
Documentation relating to your
complaint is important. This
information helps us to
understand details of your
complaint.
Please attach copies of letters
or other documents that will
help us review your complaint.
This includes your proof of
insurance, bills, receipts, a
policy declaration sheet, claim
documents, pictures or other
items that relate to your
complaint.
Always send copies.
Never send original
documents.
Desired outcome:
Please mail your complaint to:
DIFS – Office of Consumer Services
P.O. Box 30220
Lansing, MI 48909-7720
Or fax to: 517-284-8837
Or Email to: difscomplaints@michigan.gov
company, agency or licensee involved in this matter. I authorize the insurance company to release all records
(including protected health information) relating to this complaint to DIFS in order to resolve this complaint. I
My Name
Name of Insurance Company
Address
Name of AGENT or AGENCY (if applicable)
May not apply to every
complaint. Leave blank if this
does not apply.
City
State
Zip Code
Name of INSURED person
Who is covered by the policy?
My Email Address
Date of service or date of loss
Could be the date of a fire, accident,
or other loss, or the date you received
medical treatment.
Daytime phone number
( )
Alternate phone number
( )
Policy or claim number
*If this is a Health Insurance Complaint, use Health Insurance Complaint Form FIS 2257
Type of
coverage
my
complaint
is about:
Auto
Home or property
Liability
Title
Surety Bond
Life
Annuity
Long-term care
Disability Income
Other_________________________
►
Is this an employer or group plan?
□ Yes □ No
If Yes, enter employer name,
group name or group number: ____________________________________
______________________________________________________________
Have you hired an attorney to represent you in this matter?
Yes
No
Have you filed a lawsuit in this matter?
Yes
No
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Michigan form FIS-0030 - Insurance Complaint

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Completed 20 September 2019

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