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.