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TDI Complaint Process


TDI Complaint Process Valerie Brown Director, Complaints Resolution Consumer Protection Insurance Complaints An insurance complaint is any written communication ... – PowerPoint PPT presentation

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Title: TDI Complaint Process

TDI Complaint Process
  • Valerie Brown
  • Director, Complaints Resolution
  • Consumer Protection

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

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)

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

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

TDI Complaints FY 2007 Complaints Resolved
TDI Complaints FY 2007 Complaints Resolved By
Line of Coverage
2007 Provider Complaints Top Five Reasons
  • Delays claims handling
  • Denial of claim
  • Unsatisfactory settlement/offer
  • SB 418 rule violation
  • Recoupment of claims payment

TDI High-Level Complaint Processing Framework
  • 1. Receive complaint
  • Phone call
  • If customer is a Workers Compensation (WC)
    claimant, enter appropriate information in CIS
  • 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)

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.

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

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
  • Check for potential enforcement or fraud referral
  • Check for consumer education issue

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.

Complaint Data
  • Shopping resources for consumers
  • Complaint information portal page
  • Company profiles https//
  • Internet Complaint Information System
  • Carrier assessment of customer assistance
  • Stakeholder meetings (DWC/Hobby)

Complaint Referrals
  • Enforcement
  • Fraud
  • Market conduct