Understanding the Consumer Complaint Process

The Complaint Process


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Understanding the Complaint Process — Printable Version

Note: This information was developed to provide consumers with general information and guidance about insurance coverages and laws. It is not intended to provide a formal, definitive description or interpretation of Department policy. For specific Department policy on any issue, regulated entities (insurance industry) and interested parties should contact the Department.

What does the Department of Insurance do?

The Department of Insurance works to ensure all insurance companies, HMOs, producers selling insurance in Illinois and other regulated entities obey state insurance laws. The Department provides consumer information and investigates complaints about companies and producers.

What types of complaints does the Department of Insurance handle?

We handle most insurance problems involving home, business, auto, health, HMO, life, credit, dental, etc. Those problems may include coverage issues, claim disputes, premium problems, sales misrepresentations, policy cancellations, and refunds, just to name a few. We will also investigate a complaint against a public adjuster. Please follow the "How to file a complaint" steps if you want to file a complaint against a public adjuster.

The Department of Insurance cannot:

  • Act as your lawyer or give you legal advice;
  • Recommend an insurance company, producer or policy;
  • Identify an insurance company with whom a particular person may have a policy;
  • Resolve a dispute when the only evidence is your word against the word of the producer or company;
  • Make medical judgments;
  • Make determinations related to the facts of a case – For example, we cannot determine the value of damaged or stolen property or conclude who was at fault for an accident.

The Department of Insurance does not have jurisdiction over the following plans:

  1. Self-insured employers and health & welfare benefit plans – Many large employers provide health benefits for their employees through self-insured plans. Although self-insured plans are frequently administered by an insurance company, it is the employer and not the insurance company that bears the risk for paying claims. Generally, federal law exempts self-insured employer plans from state insurance regulation. The same is true of health & welfare benefit plans (union plans). However, the Department does have jurisdiction over adverse determinations of medical necessity and appropriateness to the extent required utilization review procedures are not followed by the entity performing those services for the self insured plan. In most cases, the Department of Insurance will accept your complaint and forward it to the plan in an effort to assist. We recommend you refer to your member handbook on how to file an appeal under the plan. The U.S. Department of Labor has some oversight of these plans.
  2. Federal Employees’ health and life insurance
  3. Medicare HMOs
  4. Military Insurance
  5. Policies purchased in another state (HMO policies may be the exception. Call the Department for assistance if you are covered by an HMO)
  6. Medicare
  7. Medicaid
  8. All Kids
  9. Illinois Comprehensive Health Insurance Plan
  10. State of Illinois Employee Quality Care Plan
  11. Workers Compensation

For information on how to file complaints regarding the above plans, see our Fact Sheet entitled, Contact the Proper Agency - Where To File Medicare, Medicaid and Other Health Plan Complaints on our website at Contact Proper Agency or call our Consumer Assistance Hotline toll-free number (866) 445-5364.

Before filing a complaint

  1. Contact the insurance company or agent and bring the problem to their attention. Document your phone calls by noting the name of the person you speak to, the date of the call and a brief summary of the conversation. Keep copies of all written communications.
  2. If you are not satisfied with the results you receive, contact the Department of Insurance for assistance. Insurance analysts are available to answer general questions by phone at our toll-free Consumer Assistance Hotline (866) 445-5364. However, complaints must be submitted in writing.

How to file a complaint

  1. Complaints may be submitted in the following ways
  2. When your complaint is received, a file number will be assigned and you will be sent written notification of that number. Please refer to the complaint file number when you call or write to the Department.
    • Note: A copy of the complaint will be sent to the insurance company. Illinois law allows 21 days for an insurer or agent to respond to a complaint. Please allow four to six weeks for completion of our investigation.
  3. When a response to complaint is received from the company or producer, an analyst will review the complaint and response. This review will result in one of the following actions:
    • If the complaint has been resolved, the complaint will be closed and you will be sent a letter;
    • If an insurance law has been violated, the Department will request corrective action;
    • If the company is not abiding by the policy, the Department will request corrective action;
    • If the insurer or producer has not responded to all questions or has not investigated the complaint thoroughly, the Department will require them to do so;
    • If no violation of Illinois insurance law is found, a letter will be sent to you with an explanation of the finding and notice that the investigation is being closed.
    • In each instance, you will receive a written response from the Department explaining the results of our investigation.