Insurance Ombudsman: Roles and Responsibilities

Back in 1998, the Patient’s Bill of Rights established an office of the Insurance Ombudsman in each state across America.  The provisions of that Bill were to apply to all health care plans.  The Bill included provisions such as access to care, monitoring the quality of care offered, protection of patient information, and a process for grievances and appeals.

In this article, we are going to discuss the roles and responsibilities of an insurance ombudsman, as well as the types of services they can offer to consumers.  We’ll also explain how to find an ombudsman in each area of the country.

Role of Insurance Ombudsman

The role of an ombudsman is to investigate complaints, or grievances, between parties and mediate fair settlements.  In this way, they serve as a kind of consumer advocate to ensure patients are getting the medical care they are entitled to, and deserve, from their insurance policies.


One of the responsibilities of a local ombudsman is to monitor insurance companies, and make sure they are complying with federal and / or state law.  This can also include taking a consumer advocacy position with respect to pending policy changes or availability of insurance coverage.

Another responsibility is to monitor the insurance landscape; looking for what appears to be emergent patterns of abuse.  This includes consumer complaints regarding automobile insurance claims or settlements, insurance credit scoring, homeowners insurance cancellations or non-renewals, claim and underwriting practices of insurers, as well as health insurance issues.

It is because of these roles and responsibilities that an ombudsman can often lend a hand when it comes to consumer protection issues.

Insurance Companies that Refuse to Pay

Many times, patients find themselves referred to doctors that perform special surgeries or have insights into a practice that is particularly effective in the situation they’re faced with.  However, with the growing popularity of managed health care programs such as health maintenance organizations, or HMOs, patients are often frustrated when these referrals point to doctors that are out of network.

Patients may choose to pay for the costs of these procedures out of their own pockets when insurance companies refuse to pay.  For some families, this financial burden adds to the stress and worry that comes when a loved one is suffering with an illness.  When this happens, the office of an insurance ombudsman can frequently help these families.

Insurance Appeals

An ombudsman is accustomed to looking through insurance policies, and figuring out whether or not the patient is truly entitled to the care they need.  By law, all insurance companies are required to provide patients with an appeal process.  Unfortunately, this information is usually buried deep in the policy documentation, and written in a manner that often requires an attorney to interpret the legal jargon.

The ombudsman can help patients and their families to avoid a long and costly legal battle with their insurance company by walking clients through the appeal process.  The process may take time, and may require families to gather some additional documentation; but in many cases, the appeal results in a positive outcome for the patient.

Insurance companies establish the appeals process to ensure consumers are protected.  Unfortunately, families are often too worried about their loved ones and they really don’t care, or even want to think, about going through a drawn-out process.  They just want the proper medical care to be administered.

Locating Insurance Ombudsman

The government thought the best way to ensure consumers were protected was to place an office of the insurance ombudsman in each state.  Unfortunately for the consumer, the name of the office can take many different forms:  Health Care Ombudsman, Insurance Ombudsman, and Office of Consumer Advocacy - just to name a few.

To make matters worse, the ombudsman office may be split, or specialize, in certain types of insurance.  For example, the office might specialize in Medicare versus privately held policies.  This is where the Health Assistance Partnership can help.

Funded by the Robert Wood Johnson foundation, the Health Assistance Partnership was established to meet the needs of America’s health insurance consumers.  This Partnership maintains a comprehensive list or directory of ombudsman programs located throughout the United States.  To find a specific program online, just go to the program locator section of their website.

About the Author - Insurance Ombudsman: Roles and Responsibilities (Last Reviewed on May 31, 2016)