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


The organization of health insurance complaints management in Oregon is relatively straightforward, compared to most of the other states studied. The lead agency is the Department of Consumer and Business Services. Within the Department's Insurance Division, the Consumer Assistance Unit is directly responsible for consumer complaints.

Complaints considered outside the jurisdiction of the Insurance Division include those relating to:

  1. the Oregon Health Plan which among other things extends Medicaid eligibility to all state residents with incomes below the federal poverty level, and is administered by the Office of Medical Assistance Programs within the Oregon Department of Human Services; and
  2. Medicaid - any complaints are referred directly on to the Oregon Department of Human Services.

The Consumer Assistance Unit deals with complaints about self-funded trusts identically to complaints about health plans, because of the sizeable number and growth of trusts. It contacts the plan administrator, attempts to iron out the problem and generally has outcomes similar to other health plan complaints. While the Unit will often receive quite substantive responses from these plans, the response letters regularly refer to the fact that the entity is an ERISA plan which is under no regulatory obligation to the Unit. The Unit also educates the consumer on regulatory authority and informs them of their right to seek assistance from the U.S. Department of Labor.

The Unit also handles Medicare supplement complaints, although the number has decreased substantially over the last decade, following federal action to standardize benefit packages. Oregon has an extremely active Senior Health Insurance Assistance Benefits (SHIBA) program, with the educational and outreach activities undertaken by this program helping to reduce complaints.

Complaints about Medicare HMOs are handled in the same way as those involving commercial HMOs. All the Medicare plans are owned by companies domiciled in Oregon, allowing the Unit to have reasonable leverage over them.


Oregon does not have an Ombudsman program for insurance complaints. However in 1987 the legislature mandated the establishment of a Consumer Advocacy section within the Insurance Division (Senate Bill 323, ORS 705.117). Complaints from individual consumers are dealt with by the Compliance Officers in the Unit, whereas the Consumer Advocate takes a broader systemic approach. The Consumer Advocate reports to the Manager, Consumer Protection Section, separately from the Consumer Assistance Unit.

The 1987 Annual Report for the Oregon Insurance Division notes that the primary purpose of the Consumer Advocacy Section is to administer the Division's public education program, develop legislative concepts and make recommendations for administrative action to resolve consumer issues. Regulators noted that the position description for the Consumer Advocate has recently shifted somewhat to be more collaborative working within the Insurance Division, including examining trends in complaints, monitoring the implementation of the Patient Protection Act 1997 (SB21) and working closely with the market conduct section. Another new focus is to undertake more consumer outreach.

Under Section 20 of the Patient Protection Act a Health Care Consumer Protection Advisory Committee was established as a rulemaking committee to implement the provisions of the Bill. This Committee has since disbanded.