Consumer Complaint

Required Fields are marked with an asterisk. *

Date: 05-24-2018

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Complainant's Information



Insured's Information(If different than above)

Other Parties involved in this problem

Insurance Information

*Who is the Complaint Against? Provide the name of one or more of the parties you are complaining against.



Details and Supporting Documents

4000 characters remaining.
Note: After final submission of this form you will be provided with an opportunity to attach supporting documents
If mailing supporting documents, please include a copy of this form and mail to:
Commissioner of Securities and Insurance
840 Helena Avenue
Helena, MT 59601
or FAX supporting documents along with a copy of this form to: (406) 444-1980

Authorization

The CSI will protect your records and the information you provide to us to the maximum extent of the law. The CSI will share your information only when necessary to provide the services you request or if we are required to do so by law. The CSI will only request personal information that is necessary to investigate your particular complaint. If you do not authorize the release of that information, the CSI may not be able to investigate your complaint. In certain cases, we may share information about your complaint with other government agencies that may assist us with handling your complaint. Those agencies may include the Montana Department of Labor, the United States Department of Labor, the Montana Department of Health and Human Services, the United States Department of Health and Human Services, other state insurance departments, the Montana State Health Plan or other local government health plans. In some cases, particularly in the case of internal and external appeals of health insurance claim denials, the CSI may need to refer your complaint to another agency because we do not have jurisdiction over the entity that insures you. We will advise you first before referring your complaint to another agency. Confidential information about you that we share with other government agencies must be protected pursuant to Montana law. The CSI will notify you immediately in the event that a third party initiates a legal proceeding to compel disclosure of your confidential information so that you may have an opportunity to contest such a proceeding. The CSI may, in rare cases, be compelled to disclose confidential information by a court order. Request for assistance: I hereby request the Office of the Commissioner of Securities and Insurance, Montana State Auditor (CSI), to assist me with a complaint, inquiry, or appeal regarding my insurance coverage or the conduct of an insurance company, agent, or adjuster. I grant permission to the CSI staff to review my records and information to the extent necessary to investigate my complaint. I understand that a complete copy of this complaint, including any supporting documentation, will be sent to the insurance company, agent, or adjuster that I am filing this complaint against. Authorization for release of personal information: I authorize any insurance company, health service corporation, health maintenance organization agent or producer, TPA, adjuster, or multiple employer welfare arrangement that has any record of, or knowledge about, the insured or claimant named on this form to provide information to the Office of the Commissioner of Securities and Insurance, Montana State Auditor (CSI). The information shared may be copies of any records or any other information. This includes any medical records and claim files. A copy of this authorization is as valid as the original. Electronic signature disclaimer: By completing this application electronically and by typing my name on the signature line, I agree that I have signed this application electronically. I further understand that my electronic signature has the same validity and legal force and effect as a handwritten signature under both the Uniform Electronic Transactions Act (UETA), at Mont. Code Ann. 30-18-101, et seq., and the federal Electronic Signatures in Global and National Commerce Act (E-Sign), at P.L. 106-229. I certify that the information that I have provided on this form is true and correct to the best of my knowledge.
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Agree