Health Insurance Complaint | Self-insured Plan

Complaint | Type of InsuranceHealth | Employer-providedSelf-insured


When an employer self-insures its benefit plan, it puts your contributions and the employer's contributions in a trust, and it may hire an entity (an administrator or an insurance company acting as an administrator) to perform administrative services (enroll members, provide customer service, process claims, etc.).  The employer assumes the financial risk for paying the covered claims from the trust.  In the case of a self-insured plan, no insurance policy has been purchased, so the Arizona Department of Insurance does not have jurisdiction.  Self-insured plans are generally regulated under federal laws, administered by the U.S. Department of Labor Employee Benefit Security Administration.
 

Your Next Steps

The following are steps you can take to resolve the problem you encountered:

  • Complete the appeal or grievance process established by the plan administrator.  Even if the Department of Insurance had jurisdiction, this would be your first step.
  • Seek assistance from your employer's benefits office or human resources department.
  • Evaluate whether to consult an attorney to determine your legal options if you are unsatisfied with the outcome of your appeal or grievance and assistance you received from your employer.
  • Contact the US Department of Labor if you believe the employer/plan violated federal laws covering self-insured plans.

 

Warning - Phishing Scam

We are aware of a phishing scam targeting insurance professionals claiming that the National Association of Insurance Commissioners received a complaint that the professional submitted a falsified claim. This fraudulent email displays the NAIC and CIPR logos, can originate from what appears to be an naic.org or gmail.com email account, and instructs the recipient to click on a link to download the complaint notification.

Certain antivirus products will detect this as a malicious email.  If you receive a similar email and have any concerns, contact the NAIC Service Desk at (816) 783-8500 or [email protected].