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|Ombudsman's Office - Frequently Asked Questions|
|1. What is the Office of the Insurance Ombudsman?|
|The Office of the Insurance Ombudsman is a consumer advocacy unit within the New Jersey Department of Banking and Insurance.|
|2. What are the main duties of the Office of the Insurance Ombudsman?|
Since its inception in 1998, the Ombudsman’s Office has worked closely with the Department’s Office of Consumer Protection Services to identify consumer issues that may be in need of close scrutiny and monitoring or are emergent in nature. We have focused primarily on the investigation of consumer complaint issues regarding, among others, comparative negligence settlements in automobile insurance, automobile insurance scoring, homeowner’s cancellations and nonrenewals, underground oil tank pollution claims, and mandated health insurance coverage problems.
The office also monitors insurance company compliance with insurance laws and responds to electronic or regular mail inquiries from consumers about insurance issues including, but not limited to, those regarding policy provisions and the availability of coverage.
|3. Does the Ombudsman's Office have the power to change existing laws to better protect consumers?|
|No. However through the investigatory process and the monitoring of claim and underwriting practices of insurers in the marketplace, the Ombudsman's Office works closely with the Department's Office of Legislative and Regulatory Affairs in making recommendations to change existing insurance regulations to increase consumer protections.|
|4. Who may file a complaint with the Ombudsman’s Office?|
|Any person who has a reasonable cause to believe that an insurer has failed or refuses to settle a claim in accordance with the provisions of the insurance contract or has engaged in any practice that violates state laws may file a complaint with the Ombudsman. However, in the case of disputed claims, the individual must first have filed an appeal in accordance with the insurer’s Internal Appeals Process, if applicable, prior to requesting the assistance of the Ombudsman. Disputes that are subject to Personal Injury Protection (PIP) arbitration or similar dispute resolution mechanisms are not subject to the Ombudsman’s review.|
|5. What is an Internal Appeal Process?|
|In accordance with New Jersey law (NJSA 17:29E-9), every insurer writing property and casualty or life insurance (note: health insurance is not listed in the law since these policies provide separate appeal rights) are required to have an internal appeals procedure in place for the review of disputed claims in accordance with rules and regulations promulgated by the Commissioner. The Commissioner adopted rules (NJAC 11:25 -1 et seq) outlining standards and procedures carriers must have in place.|
|6. How does the Internal Appeal Process work?|
|All insurers must provide policyholders and claimants with a written explanation of the insurer’s appeal process at some point during the claims process. The communication must describe in non-technical terms how internal appeals are processed and resolved and to whom a request for an appeal may be filed. The review must be conducted by a panel of at least three of the insurance company’s employees, who are not responsible for claims payment on a day to day basis to allow for an objective review of how the claims unit processed the claim. Internal appeals are conducted within 10 business days from receipt of the claimant’s written request.
The insurer must also have procedures in place for follow-up action, including methods to inform the claimant of the decision of the Internal Appeals Panel and their right to contact the Office of the Insurance Ombudsman if further review is requested.
|7. Do I have to fill out another form to request the Ombudsman’s review of an Internal Appeal?|
|No, the Ombudsman’s Office simply requires a request in writing; there are no formal appeal forms to complete. You should, however, submit a copy of the insurance company’s written documentation, including the denial letter and Internal Appeal Panel’s findings, as well as any pertinent documentation that may support your position as to why you believe the claim was not settled properly.|
|8. Where do I write to request a review of an internal appeal or otherwise file a formal complaint?|
You may write to us at:
The Office of the Insurance Ombudsman
|Or visit or call one of the Department’s satellite offices at the following addresses:||
Consumer Center – Camden
Consumer Center – Newark
153 Halsey Street, 2nd Floor
Newark, NJ 07102
|OPRA is a state law that was enacted to give the public greater access to government records maintained by public agencies in New Jersey.||You will need to download the latest version of Adobe Acrobat Reader in order to correctly view and print PDF (Portable Document Format) files from this web site.|
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State of New Jersey
New Jersey Department of Banking and Insurance