Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. Conclusion


Across the three employers interviewed for this study, complaints about health insurance were most likely to be used to reassess coverage decisions. None of the employers interviewed were able to provide complaints data which might shed some light on the pattern and volume of complaints, including the range of complaints related to patient protections.

The level of involvement by the employers in complaints management seemed to vary, with Caterpillar having possibly the most direct involvement which is not surprising given that it operates a self-administered health insurance plan.

Complaints data were also not a major factor in employer decisions concerning plan and provider selection or disenrollment. However the employers surveyed may use complaints to drive systemic quality improvement. For example, Caterpillar holds regular meetings with providers to seek how to improve practice, including consideration of employee complaints, while DaimlerChrysler may conduct on-site audits of plans in response to unusual patterns of complaints, albeit infrequently.

In terms of the role of employers, DaimlerChrysler stressed the importance of clear communication in helping to prevent complaints and the necessity for both employers and plans to maintain good internal appeals processes in order to limit the volume of complaints that might otherwise go to external review.