Health/Life Complaint Form

Important information about filing a complaint

This form is for filing a health, life, disability, or viatical insurance complaint with the Maine Bureau of Insurance.  If you have a complaint related to property and casualty insurance, go here. 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. Once received by the Bureau your file will be confidential as provided by Maine law.

PHOTOCOPIES of any correspondence, insurance policies, or other documentation related to your insurance problem, such as notices from the insurance company, explanations of benefits, appeal decisions, and a copy of your policy, may be necessary in order for the Division to act upon your complaint.

Your complaint will be assigned to a Claims Investigator who will contact you by mail for more information at the beginning of the investigation and will advise you of our conclusions once the investigation has been completed. This usually takes a minimum of thirty days.

We will make every effort to assist you and to see that insurance companies comply with Maine insurance laws; however, we cannot:
• Force the company to satisfy you if no laws have been broken.
• Act as your lawyer or give you legal advice.
• Make liability decisions.

If you have questions or have additional documentation to provide before you hear from a Claims Investigator, please send an e-mail to PFR, Insurance or send a fax to (207)-624-8599.

If you experience problems submitting the online forms, send an e-mail to PFR, Research.

All fields with * after them are required fields. You cannot submit your report until all required fields are completed.

PLEASE CHECK ALL THAT APPLY
Your Information
Prefix
Relationship to the Insured:
Employer Information (only complete if your insurance is purchased through an employer). Please list the name of the employer who provides your insurance. If your insurance is not through your employer, please list the employer of the primary insured (for example, your partner’s or your parent’s employer).
Insureds Information
Prefix
Insurance Information
Agent Information (if applicable)
Details of Complaint
Consumer Authorization

I hereby authorize that any hospital, physician, osteopath, chiropractor or other health care provider, or any person, or company regulated by the Maine Bureau of Insurance, to 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 12 months from the date the authorization is signed or until I revoke it in writing.

I acknowledge that, by filling out and submitting this form, I am the policyholder or enrollee named in this complaint, or that person’s legal representative, and that my signature and e-mail address are in the boxes below.