Consumer Protection in Private Health Insurance: The Role of Consumer Complaints. Policy Implications and Recommendations


The multiplicity of agencies involved in oversight of health insurance complaints makes it difficult to develop a comprehensive picture of how well insurance plans are performing on consumer complaints. However, the pursuit of uniform models of health insurance complaints management is not recommended at this time. Instead, it is recommended that strategies be developed which clarify responsibility, facilitate communication and enhance the knowledge and experience of regulators in complaints management. Strategies which have been identified at state level include the use of a Memorandum of Understanding to clarify responsibility where there is shared authority, periodic meetings of federal and state regulators and the development of a single entry point for consumer complaints about health insurance.

Independent ombudsman or consumer assistance programs are essential in ensuring accountability of state insurance regulatory agencies and in providing an alternative, more approachable forum for consumer complaints. They can also play a vital role in resolution of consumer complaints through mediation and in undertaking systemic advocacy based on complaints analysis. The independence and accountability of ombudsman programs needs to be fostered through statutory authority, dedicated funding and a requirement for reporting to the legislature and general public.

Comparative complaints and grievance data should be more widely publicly available to enhance the accountability of health insurance plans to all stakeholders including consumers, employers, purchasers, policy-makers, legislators and regulators. Complaints report cards can be improved through design features including: the presentation of complaints data as part of a suite of performance measures and in conjunction with contextual information on the health insurance market; the incorporation of consumer-friendly performance measures and presentation formats such as grades and simple graphical formats; and the use of decision-support methods and expert global advice.

Grievance data provide a potentially rich source of information in understanding the implementation of patient protections. Analysis of grievance data, including the rate at which grievances are reversed in favor of consumers, can be used to identify areas where public education may be required, new legislative protections may be needed or improvements in monitoring health insurance plan performance may be warranted. However variations across states in how complaints are measured, the legislative environment and the complaints handling system mean that these analyses are likely to be of most value to regulators within states, rather than in developing a national picture. It is recommended that regulators design reporting frameworks for grievances which closely match the patient protections in the relevant jurisdiction and that grievance data are subject to audit to ensure validity.