Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. A. Jurisdiction and Responsibility for Consumer Complaints Systems


Two state government departments, the Department of Insurance and the Department of Health, share responsibility for health insurance complaints.

The Department of Insurance Consumer Services Bureau is responsible for complaints concerning payment, reimbursement, coverage, benefits, rates and premiums, while the Department of Health Office of Managed Care is responsible for complaints relating to quality of care and adequacy of providers. Both Departments collaborate on the production of, and contribute data to, the complaints report card, "New York Consumer Guide to Health Insurers".

For complaints involving other payers such as Medicare and Medicaid, the role of the Department of Insurance will depend upon the nature of the complaint. For example, Medicaid complaints involving prompt payment (statutory requirement for claims to be paid within 45 days) are under the jurisdiction of the Department of Insurance. However for most complaints, the Department of Insurance refers the consumer to the responsible agency (i.e. HCFA(now known as CMS) for Medicare complaints and State Department of Health for Medicaid complaints).

New York also enacted an external review process which took effect from 1 July 1999 which applies to private insurance and Medicaid, but not Medicare-only beneficiaries. Under this process consumers have up to 45 days from the date of receiving a final adverse determination through a plan's internal appeal process to make an application to the Department of Insurance for external review.

There has been no discussion about the establishment of an ombudsman office. Regulators at the Department of Insurance believe that the Department's Consumer Services Bureau is generally considered to be equivalent to an ombudsman office. The Consumer Services Bureau will recommend legislation based on analysis of patterns of complaints (e.g. prompt pay, external review).