Reasons Why Closed Confirmed Consumer Complaints Were Reported
As of June 29, 2015
Data reflected in this report is voluntarily submitted to the NAIC proprietary Complaints Database System (CDS) by state
insurance departments. Not all states provide all of their complaint data to the NAIC. Aggregate report data retrieved is specific
only to risk bearing entities within the database and does not include information on specific agents/brokers. Complaints
retrieved are those states deem confirmed. The NAIC does not guarantee the truth, accuracy, quality or completeness of the
data and is not responsible for errors, omissions or for results of further use.
Report Description: The Reasons Why Closed Confirmed Consumer Complaints Were Reported report provides the counts
and percentages of the reasons consumers complain about their coverage (claim delays, claim denials, cancellation, premium
increases, etc.). The Top 10 Reasons section of the report provides a listing of the top 10 reasons with counts and
percentages of total counts. The All Reasons section provides the counts for all reasons from the NAIC's Complaint Database
System. The data codes identified are based on the NAIC Standard Complaint Data Form.
A Closed Complaint is a complaint that has been investigated by the state insurance department, and given a resolution
code.
A Confirmed complaint is a complaint in which the state department of insurance determines:
a) The insurer, licensee, producer, or other regulated entity committed any violation of:
1) an applicable state insurance law or regulation;
2) a federal requirement that the state department of insurance has the authority to enforce; or
3) the term/condition of an insurance policy or certificate; or
b) The complaint and entity’s response, considered together, indicate that the entity was in error.
Top 10 Reasons
2015
Reason for Complaint
Claim Handling - Delays
Claim Handling - Denial of Claim
Underwriting - Surcharge
Claim Handling - Unsatisfactory Settlement/Offer
Claim Handling - State Specific
Underwriting - Cancellation
PolicyHolder Service - Coverage Question
PolicyHolder Service - Premium Refund
PolicyHolder Service - Premium Notice/Billing
PolicyHolder Service - Delays/No Response
% of All
Count Reasons
5,935
17.01%
4,998
14.32%
4,792
13.73%
3,282
9.41%
1,537
4.40%
1,445
4.14%
1,408
4.04%
1,266
3.63%
1,107
3.17%
1,027
2.94%
2014
Reason for Complaint
Claim Handling - Delays
Claim Handling - Denial of Claim
Claim Handling - Unsatisfactory Settlement/Offer
Underwriting - Cancellation
Claim Handling - State Specific
PolicyHolder Service - Premium Refund
PolicyHolder Service - Delays/No Response
PolicyHolder Service - Coverage Question
PolicyHolder Service - Premium Notice/Billing
Underwriting - Premium & Rating
% of All
Count Reasons
13,429
20.01%
11,060
16.48%
7,370
10.98%
3,493
5.21%
3,417
5.09%
2,829
4.22%
2,763
4.12%
2,633
3.92%
2,518
3.75%
2,014
3.00%
Recipient agrees not to market, sell or distribute this data/report without the prior written consent of the NAIC. For reprint
permission please see www.naic.org/jsp/legal_reprints.jsp.
Report reflects data reported from the state insurance departments to the NAIC as of 06/29/2015.
Database: DSPLP
© 1990 - 2015 National Association of Insurance Commissioners. All rights reserved.
Page 1 of 6
Reasons Why Closed Confirmed Consumer Complaints Were Reported
As of June 29, 2015
2013
Reason for Complaint
Claim Handling - Delays
Claim Handling - Denial of Claim
Claim Handling - Unsatisfactory Settlement/Offer
Claim Handling - State Specific
Underwriting - Cancellation
PolicyHolder Service - Premium Refund
PolicyHolder Service - Coverage Question
Underwriting - Premium & Rating
PolicyHolder Service - Premium Notice/Billing
Claim Handling - Adjuster Handling
% of All
Count Reasons
11,806
23.84%
7,739
15.63%
5,593
11.29%
2,271
4.59%
2,202
4.45%
1,943
3.92%
1,934
3.90%
1,640
3.31%
1,400
2.83%
1,300
2.62%
2012
Reason for Complaint
Claim Handling - Delays
Claim Handling - Denial of Claim
Claim Handling - Unsatisfactory Settlement/Offer
Claim Handling - State Specific
Underwriting - Cancellation
Underwriting - Premium & Rating
PolicyHolder Service - Premium Refund
PolicyHolder Service - Coverage Question
PolicyHolder Service - Premium Notice/Billing
Underwriting - Nonrenewal
% of All
Count Reasons
11,321
21.62%
8,112
15.49%
7,204
13.76%
2,676
5.11%
2,667
5.09%
1,904
3.64%
1,891
3.61%
1,880
3.59%
1,429
2.73%
1,357
2.59%
Recipient agrees not to market, sell or distribute this data/report without the prior written consent of the NAIC. For reprint
permission please see www.naic.org/jsp/legal_reprints.jsp.
Report reflects data reported from the state insurance departments to the NAIC as of 06/29/2015.
Database: DSPLP
© 1990 - 2015 National Association of Insurance Commissioners. All rights reserved.
Page 2 of 6
Reasons Why Closed Confirmed Consumer Complaints Were Reported
As of June 29, 2015
All Reasons
Code
805
807
808
809
810
815
816
818
819
820
821
822
825
828
829
830
835
836
837
840
845
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
Underwriting
1101
1103
1104
1105
1107
1110
1113
1115
1118
1120
1121
1122
1123
1125
1126
1129
1130
1131
1132
1133
1134
1135
1136
1137
1138
1139
1140
1141
1142
1143
1144
1145
1146
1147
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
PolicyHolder Service
Database: DSPLP
Reason for Reporting Complaint
Premium & Rating
Dependent Age
Pre-existing Condition
Waiting Periods
Refusal to Insure
Cancellation
Nonrenewal
Credit Report
Redlining
Delays
Forced Placement
Audit Dispute
Unfair Discrimination
Rescission
Surcharge
Endorsement/Rider
Group Conversion
CLUE Reports
MIB Reports
Continuation of Benefits
State Specific
Inadequate Provider Network
Class Action
1035 Exchange
Premium Notice/Billing
Surrender Problems
Cash Value
Accelerated Benefits
Delays/No Response
Policy Delivery
Premium Refund
Nonforfeiture
Viatical Settlement
Payment Not Credited
Coverage Question
Access to Care
Abusive Service
State Specific
Credentialing Delay
Involuntary Termination by Plan
Provider Listing Dispute
Delayed Appeal Consideration
Delayed Authorization Decision
Access to Fee Schedule/Rates
Inadequate Reimbursement Rates
Unfair Negotiation
Premium Subsidy
Wellness Program
Essential Community Provider
Choice of PCP (Primary Care Provider)
Disabled Individuals' Access
MLR (Medical Loss Ratio) Rebate
Language Access
Notice Requirements
Continuity of Care
2015
993
5
7
2
76
1,445
310
11
1
145
8
42
6
10
4,792
25
6
25
2
44
98
2014
2,014
2
15
8
198
3,493
895
32
1
339
17
73
13
50
775
54
6
78
3
99
368
2013
1,640
0
2
0
245
2,202
1,082
16
3
250
17
86
23
56
637
49
6
43
3
87
422
2012
1,904
0
19
0
270
2,667
1,357
35
2
191
14
53
11
53
838
61
12
37
4
83
551
46
2
8
1,107
113
87
5
1,027
180
1,266
4
0
283
1,408
179
131
493
21
106
38
13
22
6
45
4
51
2
1
10
2
0
0
39
17
70
3
22
2,518
232
250
2
2,763
544
2,829
11
2
472
2,633
320
172
1,400
25
256
87
12
44
14
71
18
36
3
0
25
1
1
1
42
22
10
4
17
1,400
185
187
4
1,229
153
1,943
16
0
156
1,934
52
175
1,018
8
24
22
13
33
4
20
19
0
0
0
0
0
0
0
0
0
12
6
10
1,429
193
147
1
1,281
155
1,891
9
0
195
1,880
49
152
1,031
0
15
3
3
9
3
6
10
0
0
0
0
0
0
0
0
0
© 1990 - 2015 National Association of Insurance Commissioners. All rights reserved.
Page 3 of 6
Reasons Why Closed Confirmed Consumer Complaints Were Reported
As of June 29, 2015
All Reasons
Code
Reason for Reporting Complaint
2015
2014
2013
2012
Recipient agrees not to market, sell or distribute this data/report without the prior written consent of the NAIC. For reprint permission please
see www.naic.org/jsp/legal_reprints.jsp
Report reflects data reported from the state insurance departments to the NAIC as of 06/29/2015.
Database: DSPLP
© 1990 - 2015 National Association of Insurance Commissioners. All rights reserved.
Page 4 of 6
Reasons Why Closed Confirmed Consumer Complaints Were Reported
As of June 29, 2015
All Reasons
Code
1001
1002
1003
1004
1005
1006
1007
1009
1010
1012
1013
1015
1017
1018
1019
1020
1021
1022
1025
1028
1030
1035
1036
1037
1038
1039
1040
1041
1042
1043
1044
1045
1046
1047
1048
1049
1050
1051
1052
1053
1054
902
903
904
905
906
908
911
913
915
918
919
922
923
924
926
929
930
931
933
Database: DSPLP
Reason for Reporting Complaint
Adjuster Handling
Prompt Pay
Willing Provider
Provider Availability
Unsatisfactory Settlement/Offer
Preexisting Condition
Medical Necessity
Fraud
PostClaim Underwriting
Subrogation
Comparative Negligence
Denial of Claim
Usual, Customary, Reasonable Charges
Out-of-Network Benefits
Co-pay Issues
Coordination of Benefits
No Preauthorization
PCP Referrals
Delays
Assignment of Benefits
Cost Containment
State Specific
Appeal Non-Compliance
Claim Recoding/Bundling
Recoupment
Annual Limit
Essential Health Benefit
External Review
Internal Appeal
Lifetime Limit
Preventive Care
Pharmacy Benefits
Maternity and Newborn Care
Emergency Services
Mental Health Parity
Maximum Out of Pocket
Ambulatory Patient Services
Hospitalization
Rehabilitative/habilitative Care
Pediatric Care
Laboratory Services
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Claim Handling
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Unfair Discrimination
Suitability
Financial Privacy
Misleading Advertising
Health Privacy
Replacement
Unauthorized Entity
Fiduciary/Theft
Misrepresentation
Misappropriation of Premium
Not Appointed w/Company
High Pressure Tactics
Duplication of Coverage
Rebating
Misstatement on Application
Fraud/Forgery
State Specific
Excess Compensation Without Agreement
Failure to Submit Application
2015
810
311
5
55
3,282
48
217
19
17
37
129
4,998
35
326
316
130
88
16
5,935
90
83
1,537
22
14
101
14
14
10
17
2
42
129
24
74
11
56
6
22
16
17
13
2014
1,403
828
10
118
7,370
128
446
27
29
102
235
11,060
120
534
564
259
178
27
13,429
120
247
3,417
34
42
158
13
13
9
13
4
44
106
9
48
4
39
6
12
5
2
4
2013
1,300
626
4
39
5,593
143
391
23
50
61
196
7,739
130
365
345
208
98
30
11,806
70
94
2,271
21
39
127
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
2012
1,097
416
3
28
7,204
158
398
31
46
76
222
8,112
132
437
304
245
100
18
11,321
77
81
2,676
2
17
57
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
70
2
45
6
26
7
13
342
50
6
25
22
3
19
30
248
27
9
6
187
2
88
10
103
23
44
655
81
13
36
75
4
42
78
782
27
42
8
163
7
56
5
92
20
66
441
78
10
40
54
4
23
56
1,028
4
38
8
141
3
66
3
98
26
80
466
85
6
38
38
6
18
91
1195
2
48
© 1990 - 2015 National Association of Insurance Commissioners. All rights reserved.
Page 5 of 6
Reasons Why Closed Confirmed Consumer Complaints Were Reported
As of June 29, 2015
All Reasons
Code
934
935
936
937
938
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Marketing & Sales
Reason for Reporting Complaint
Premiums Misquoted
Other Violation of Insurance Law/Regulation
Adjuster Working for a Company Not Licensed
Using an Unlicensed Name
Summary of Benefits
2015
43
19
1
0
23
2014
87
49
1
2
10
2013
42
27
0
2
0
2012
11
16
0
0
0
Recipient agrees not to market, sell or distribute this data/report without the prior written consent of the NAIC. For reprint permission please
see www.naic.org/jsp/legal_reprints.jsp
Report reflects data reported from the state insurance departments to the NAIC as of 06/29/2015.
Database: DSPLP
© 1990 - 2015 National Association of Insurance Commissioners. All rights reserved.
Page 6 of 6