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Maine.gov > PFR Home > Insurance Regulation > Consumer Complaint Form

STATE OF MAINE
HEALTH INSURANCE CONSUMER COMPLAINT FORM

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In response to your request for our assistance, below is a Consumer Complaint Form which must be completed and returned to this office. The form authorizes the Bureau to investigate the matter on your behalf; and provides us the basic information we need to investigate your complaint. The form may be submitted either electronically or by mail. If you choose to send the electronic form, the Bureau cannot guarantee the confidentiality of your complaint during electronic transmission. Once received by the Bureau your file will be confidential.

PHOTOCOPIES of any correspondence, insurance policies, or other documentation related to your insurance problem (such as letters you have written about your complaint, letters or other written material you have received about your complaint, explanation of benefits forms, invoices, a copy of the part of your insurance policy or benefits handbook relating to your concern, any notes you have taken while talking to the company about your problem etc.) may be necessary in order for the Division to act upon your complaint.

The investigator assigned to your complaint will send you a letter within a week of the date the complaint is received.

Please note the Bureau does not have authority to order the payment of monetary judgments, although in some instances we can order restitution for violations of the Insurance Code. Some disputes are more appropriately handled by the courts. We are often able to help, however, and we will make every effort to see that you are treated fairly by the insurance companies we regulate.

Bureau of Insurance
Consumer Health Care Division
34 State House Station
Augusta, ME 04333-0034
 
Tel: (207) 624-8475
Toll Free: 1-800-300-5000
Fax: (207) 624-8599

1. CONSUMER INFORMATION









2. INSURANCE INFORMATION









3. CONSUMER AUTHORIZATION

I hereby authorize that any hospital, physician, other health care provider, person, or company regulated by the Maine Bureau of Insurance may provide the Bureau with any medical information or records needed by the Bureau to investigate my complaint. I specifically authorize release of information about mental health and substance abuse treatment as needed to investigate this complaint. This authorization remains in effect until I revoke it in writing.





 

Last Updated: June 24, 2009