q117/random_k4/random_3.md

Colorado Division
of Insurance Annual
Complaint and
Recoveries Report

FY 2023-24 (July 2023 - June 2024)

Contents
Facts and Figures  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �   4

Digging Deeper Into Issues �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �   6

Helping Coloradans Navigate Homeowners Insurance

6

Answers and Education � � � � � � � � � � � � � � � � � � � � � � � � 7

Digging Deeper Into Issues �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �   8

Providing a Better Understanding of Health Insurance

8

Out-of-Network Labs � � � � � � � � � � � � � � � � � � � � � � � � � � 8

Helping Consumers Understand Long-Term Care Insurance
Policy Options  � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 9

Consumers’ Stories  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  �  � 10

Delay in Hail Damage Claim  � � � � � � � � � � � � � � � � � � � � 10

Transplant Results in Out-of-Network Billing  � � � � � � � � � 10

Smoke Damage from Marshall Fire � � � � � � � � � � � � � � � � 11

Following Through on Network Exception  � � � � � � � � � � � 12

Improper Delay for Life Insurance Claim � � � � � � � � � � � � 12

Travel Insurance Not Paying Hospital Bill � � � � � � � � � � � � 13

Getting Medical Claims Paid � � � � � � � � � � � � � � � � � � � � 13

Contact the Colorado Division of Insurance   �  �  �  �  �  �  �  �  �  �  �  14

2  |

Colorado Division of Insurance Annual
Complaint and Recoveries Report

FY 2023-24 (July 2023 - June 2024)

The Colorado Division of Insurance (DOI), part of the Department of Regulatory Agencies
(DORA), regulates insurance in Colorado - the insurance companies as well as insurance
agents/brokers. But the DOI is also a resource for Coloradans on insurance matters. We
answer consumers’ questions, investigate consumers’ complaints and generally explain
the world of insurance to the public. Most of this work is done by the Consumer Services
Team, which is split into two components - Property & Casualty Insurance and Life & Health
Insurance. The Consumer Services Team also works with other DOI teams as necessary,
especially when systemic issues with insurance companies are identified through complaints
received and interactions with consumers.

This report covers the consumer complaints submitted to the DOI, the work in investigating
the complaints, and the money recovered for consumers throughout the 2023-24 fiscal year
(FY 2023-24; July 2023 - June 2024). During that fiscal year, the Consumer Services Team
received more complaints as compared to the previous year, and recovered more money
for Coloradans.

For the Property & Casualty section, complaints were mostly centered around homeowners
and auto insurance. This group not only investigated and resolved these complaints, but also
worked to educate consumers regarding the current challenges in the homeowners insurance
market and served as a valuable resource by providing assistance to consumers in Colorado.

The Life & Health group received fewer complaints compared to the previous year. However,
they investigated nearly 2,000 complaints while helping consumers navigate their health
insurance.

Ensuring access to care for Colorado consumers continued to be top of mind for the DOI in
working through consumers’ questions and complaints.

  | 3

Money Recovered for
Colorado Consumers

Facts and
Figures

This is money that goes to consumers in situations where
the DOI finds that an insurance company improperly
denied a claim, or did not initially pay the correct claim
amount. Recoveries can also come about when a company
is delaying payment on a claim or has not followed State
insurance law and regulations.

Property & Casualty Insurance

Total Money
Recovered
for Colorado
Consumers
$26,487,192

(an increase over the previous
year’s total of $21,523,066)

Money recovered
on homeowners
insurance complaints

$10,601,710

Money recovered
on auto insurance
complaints
$4,995,340

$19,253,299
total recovered

Life & Health Insurance

Money recovered
on health insurance
complaints

$4,080,002

Money recovered on
life insurance and
annuity complaints
$3,152,428

$7,232,430
total recovered

4  |  Facts and Figures

Facts and Figures

Property & Casualty
Insurance Complaints

Life & Health
Insurance Complaints

Total Property &
Casualty Insurance
Complaints Received

3,829

1,929

Total Life & Health
Insurance Complaints
Received

Complaints
specifically related
to homeowners
insurance

1,504

Complaints
and Inquiries
Received
6,987

Complaints and
Inquiries Closed
 7,327

1,716

Complaints
specifically related
to health insurance

Note:  Some  complaints  take  longer  than  others  to  fully
investigate, so not all complaints are resolved in the year they
are received. This figure also includes 2,218 inquiries, which
are instances when a consumer’s complaint involves an easily
resolved question or falls outside of the DOI’s authority to
regulate. These complaints still require the Consumer Services
Team to contact the consumer to answer their questions and
educate them on their options.

14,741

Telephone Calls: 14,741

Calls  to  the  Consumer  Services  Team  can  include  simple
questions regarding a claim or insurance policy, inquiries about
a company’s actions which may violate State insurance laws or
how to submit a formal complaint to the DOI

Facts and Figures | 5

DOI’s Work

Digging
Deeper
Into Issues

Helping Coloradans Navigate
Homeowners Insurance

Across the country, including here in Colorado,
people are working through challenges with
their homeowners insurance. The DOI has been
implementing a number of ways to address
these issues, including legislation like the FAIR
Plan (an insurer of last resort), market studies
and regular stakeholder meetings to hear from
consumers and share information about the
DOI’s efforts. Our Consumer Services Team has
also been working through these challenges
with individual consumers.

6  |  DOI’s Work - Digging Deeper Into Issues

Digging Deeper Into Issues

Answers and Education

In the last year, the Team fielded about 570 calls
and emails from Colorado consumers concerned
about  the  affordability  and  availability  of
homeowners insurance, as well as non-renewals,
which represented about 35% of all the calls and
emails the team received specifically related to
homeowners insurance.

With each of these inquiries, a Team member takes
the time necessary to educate the consumer about
the factors leading to premium increases, the
underwriting decisions of insurance companies,
and  the  claims  process,  while  also  providing
resources to help find coverage and suggestions
to possibly lower premiums.

DOI’s Work - Digging Deeper Into Issues | 7

DOI’s Work

Digging
Deeper
Into Issues

Providing a Better
Understanding of Health
Insurance

In recent years, the DOI developed various programs
that increase access to health insurance and save
people money on health care. However people can
still run into problems and roadblocks when using
that health insurance. The Consumer Services Team
strives to not only answer people’s questions and
investigate their complaints, but also works to
help people gain a better understanding of their
coverage and benefits, and help them navigate the
health care system.

Out-of-Network Labs

Over the last year, the Consumer Services Team has seen an
uptick in complaints about physicians sending blood draws
and other lab work to out-of-network labs. Generally, this
shouldn’t occur, as in-network physicians are required by
their contract with insurance companies to use labs that
are  also  in-network.  In  addition  to  investigating  each
consumer complaint to ensure that consumers are receiving
the benefits promised by their insurance policies, the Team
is currently working with insurance companies to address
this challenge and ensure members’ labs are being sent to
in-network providers by their contracted care teams.

8  |  DOI’s Work - Digging Deeper Into Issues

Digging Deeper Into Issues

Helping Consumers Understand Long-Term Care
Insurance Policy Options

In this past year, the Consumer Services Team successfully
helped many consumers understand their Long–Term Care
(LTC)  policies,  as  well  as  what  options  are  available  to
them when they experience a rate increase. The Team also
worked to gain a deeper knowledge about how LTC insurance
companies interpret their policies and determine payouts to
their policyholders. Through this effort, the Team identified
a specific policy option that could help many Coloradans.
An “Alternate Plan of Care” option is designed to provide
consideration for care that would not normally be covered
under LTC policies. And while this policy option can only be
accessed in very specific circumstances, the Team was able to
identify it as an option for specific consumers that had filed
complaints concerning coverage that was dependent on the
type of facility in which the care was received. In some cases
this allowed the policyholders to access policy benefits without
having to change the facility in which they were residing.

DOI’s Work - Digging Deeper Into Issues | 9

Consumers’
Stories

10  |  Consumers' Stories

Delay in Hail Damage Claim

The owners of an apartment complex filed a complaint
after an extensive delay in getting payment on a claim
regarding extensive hail damage to the complex.
The hail claim was filed on July 24, 2023, yet as of
November 2023, the insurance company had still not
paid the settlement amount. After the apartment
complex filed a complaint with the DOI on November 1,
the DOI contacted the insurance company, prompting
the company to start working with the complex to
negotiate the settlement. By November 22, 2023, the
insurance company had paid the settlement amount
of $2,657,730.

Transplant Results in Out-of-Network
Billing

The Team worked with a consumer with medical bills
over $420,000 due to a transplant. The consumer had
been insured by Friday Health, and even though the
company had made the appropriate arrangements
with the out-of-network health care providers, Friday
Health had been liquidated throughout the country
and put into receivership. The Consumer Services
Team worked with the providers to pause bills to
the consumer while working through the transplant
claims and provider payments. The Team also worked
with an outside advocacy agency, and ultimately the
consumer was not billed for anything over in-network
charges.

Consumers’ Stories

Smoke Damage from Marshall Fire

Unfortunately, some consumers are still working through
issues resulting from the December 2021 Marshall Fire.
One consumer filed a complaint in November 2022, as their
insurance company had still not remediated the smoke
damage to their home. While the company did agree to
do some cleaning, it was not to the extent the consumer
needed. With the Consumer Services Team’s involvement,
the company eventually paid an additional $122,197 to
properly clean and remediate the smoke damage to the
home, and the Team was able to close the complaint in
August 2023.

Consumers' Stories | 11

Consumers’ Stories

Following Through on Network Exception

With health insurance, issues around provider networks are
common. When Coloradans run into problems with a provider
network being inadequate in rural areas or regarding speciality
care and speciality providers, consumers will often require what is
called a Provider Network Gap Exception so they can get the care
they need. The Consumer Services Team makes sure the insurance
companies follow through and approve these exceptions as
necessary. In the last year, the Team worked through a consumer’s
exception that had been approved by Oscar Health. However, this
exception was complicated by the fact that Oscar had not set
up the appropriate agreement, called a Single Case Agreement
(SCA), with the out-of-network speciality provider. Additionally,
Oscar Health had exited the Colorado market. As a result, the
consumer was billed for over $30,000. The Team intervened to
ensure that Oscar Health processed the claim correctly, and the
consumer was covered at no greater cost to the consumer than
if the services and treatment were obtained from an in-network
provider.

Improper Delay for Life Insurance Claim

The DOI often needs to intervene when a life insurance policy
payout is delayed. In one particular case, a person was expecting
a payout of over $2 million from two policies. The claims were
filed on March 10, 2023, and the consumer battled with the
insurance company over the next three months to get this settled.
Even after the company received a coroner report, it did not
issue the payout. Finally, the consumer filed a complaint with
the DOI on July 14, 2023. After a DOI investigation, the company
processed the claim and made the payments by July 26, including
over $14,000 in interest.

12  |  Consumers' Stories

Consumers’ Stories

Travel Insurance Not Paying Hospital Bill

A Colorado consumer purchased travel insurance, which included medical
coverage, for an overseas trip. A health emergency occurred early in the trip. In
January 2023, the foreign hospital billed for services in the amount of $48,656.
Yet, as of November 2023, the travel insurance had still not paid for this bill.
The consumer submitted a complaint to the DOI on November 28. The travel
insurance company was attempting to renegotiate the bill, however, based on
the DOI’s involvement, they wrapped up their review of the claim and paid the
full amount to the hospital by late December 2023.

Getting Medical Claims Paid

For  many  people,  struggling  with  traumatic
medical problems can mean they do not have the
energy to navigate the health care system. The
Consumer Services Team worked with a consumer
whose wife was involved in a car accident that
resulted in a traumatic brain injury. She had been
moved multiple times from one facility to another
and was having claims denied.  The Team worked
with  the  insurance  company  to  get  a  better
understanding of the claims, as well as the claim
denials. Eventually, our Team ensured the claims
were paid, providing an immense sense of relief
for the family.

Consumers' Stories | 13

Contact the Colorado
Division of Insurance

If you have questions, concerns or complaints about your insurance,
insurance company or insurance agent, or you just need an explanation
of terminology, processes or the world of insurance in general, please
contact the Colorado Division of Insurance Consumer Services Team.

303-894-7490

DORA_Insurance@state.co.us

doi.colorado.gov (click on “File a Complaint”)