Mike Causey | Got a question about insurance? We can help

If you’ve ever had a difficult time understanding an insurance policy or your Explanation of Benefits statement, you’re not alone. Insurance can be confusing. If you’re having trouble understanding an insurance document or don’t know how to deal with your insurance company when you have a claim, I have some good news for you.

We have an entire group of dedicated consumer experts at the Department of Insurance whose full-time job is to help you understand insurance-related issues so you can make informed decisions for you and your family. They’re here to help you if you have questions about insurance, need to file a complaint or want to report suspected insurance fraud.

We aim to respond promptly, clearly and courteously to your insurance-related questions and complaints, assist you in resolving those complaints whenever possible, and help you understand your options for dealing with insurance-related matters.

We seek fair treatment of all parties in insurance transactions. We are here to serve you.

Here are some of the things we can do:

— Forward a copy of your complaint to your insurance company and require the company to provide a response/explanation.

— Review the company’s response for compliance with applicable North Carolina statutes, regulations, and policy requirements.

— Require the company to take corrective action if we determine that the company’s position does not comply with applicable requirements.

— Help you understand your insurance policy.

— Recommend courses of action that you can take to resolve your problem if we do not have the regulatory authority to resolve it ourselves.

— If your situation involves a health plan’s noncertification decision (denial based on lack of medical necessity), refer you to the Department of Insurance’s Healthcare Review Program (HCR Program), for further guidance.

Here are some of the things we cannot do:

— Act as your legal representative in or out of court.

— Intervene in a pending lawsuit, on your behalf.

— Consult with you if you are represented by an attorney unless we have your attorney’s written permission.

— Regarding a dispute between you and your insurance company, establish:

• Who was negligent or at fault.
• The value of a claim or the amount of money owed to you.
• The facts surrounding the claim (that is, who is being truthful when there are differing accounts of what happened).
• The facts regarding any other disagreement between you and another party.
• Address plans or companies that are not subject to the insurance laws of North Carolina, or that are governed by other state agencies.
• The North Carolina Department of Insurance pledges to seek fair treatment of all parties in insurance transactions. We are here to serve you.

If you wish to report fraud, you may go to www.ncdoi.gov/fraud-control/report-insurance-fraud. Or you may call us at 919-807-6840 or toll-free from anywhere in North Carolina at 888-680-7684.

You may file a complaint by going to www.ncdoi.gov or by calling toll-free 855-408-1212 from 8 a.m. to 5 p.m. Monday through Friday.