Where can you complain about an insurance company, a doctor and a health insurance clinic: the Central Bank, Rospotrebnadzor and other departments. Insurance companies create call centers to help with compulsory medical insurance First insurance center for customer complaints

From July 1, insurance representatives will start working in the system of compulsory medical insurance (CHI) throughout Russia, said Dmitry Kuznetsov, president of the Interregional Union of Medical Insurers (IMS). These are call centers with specialists in the protection of the rights of the insured and expert doctors who will have to help people quickly solve problems associated with treatment under compulsory medical insurance.

The main goal is to build a unified system of relationships between insurers and CHI clients and convey to people that the easiest way to solve problems is to contact the insurance company, and not write a complaint to the Ministry of Health, the Federal Compulsory Medical Insurance Fund (FFOMS) or another department.

“If the questions relate to the lack of medical personnel, the lack of the necessary diagnostic equipment in a medical organization, the provision of subsidized medicines, this is the competence of the health authorities. Here it is better to contact the head physician of the medical institution or Roszdravnadzor, - Interfax quotes Kuznetsov. “But if the questions are related to the organization of the provision of medical services, their timeliness and proper quality, consultation of the compulsory medical insurance insurer, insurance representative will help.”

Call centers are created on the basis of the territorial funds of the FFOMS, it follows from his words. All specialists of the new information center will be divided into three levels depending on their competencies and the complexity of the problems being solved. Employees of first-level call centers will answer typical questions: where to get a policy, how to attach to a polyclinic, how it works. Specialists in the protection of the rights of the insured will advise on how to resist the imposition of paid services, talk about other rights of citizens under compulsory medical insurance, and also help solve problems, for example, with hospitalization. An expert doctor will advise on the quality of medical care, the adequacy of recommendations for obtaining medical services, Kuznetsov points out.

Much of what is being introduced is already working in large federal insurance companies, he admits, and now it will appear throughout Russia in a single format. Different companies had their own advantages in solving some issues in a particular territory, the creation of this system is an attempt to combine all the positive experience, he says.

Whip for doctors

On June 7, the government submitted to the State Duma a bill on the introduction of fines for violations of patients' rights. For individuals, they amount to 15,000–20,000 rubles, for legal entities - up to 300,000 rubles. Penalties will be applied, among other things, for failure to provide the patient with information about his rights.

In addition, call center specialists will have a new function - to remind them of the need to undergo a preventive examination. An adult is supposed to take it every three years, Kuznetsov continues. The Ministry of Health expects that the introduction of this system of reminders will help increase the number of people who undergo medical examinations in a timely manner, one of the major insurers, who is present at meetings with representatives of the department, admits.

Insurers are ready for innovation. Alfastrakhovanie-OMS has already trained specialists at all levels to start full-fledged work from July 1, says Yegor Safrygin, director of the Medicine department: “People often do not know what is included in the basic compulsory medical insurance program, where is the line between paid and free. Experts will be able to advise, give the necessary instructions. Ingosstrakh-M also announced its readiness for work.

A significant part of the work of call center employees will consist precisely in increasing the interest of citizens in undergoing medical examinations, says Lyudmila Romanenko, adviser to the general director of Sogaz-med. They will also track people's satisfaction with the quality of medical care, its timeliness, find out the reasons for refusals to hospitalize, she lists.

With the consent of clients, especially those with chronic diseases, insurance representatives will even remind you of the need for dispensary observation in order to rule out relapses, she says. Lists of people will be provided by medical institutions.

In countries with an insurance model of health care, citizens turn to the insurer with emerging questions, says Nina Galanicheva, CEO of Rosno-MS (part of Allianz). But this form of insurance representatives, according to her, is a unique experience for Russia. This is a movement towards the formation of a patient-centered model, she points out. She believes that one of the main tasks of the new system is to provide assistance to the insured in obtaining free medical care.

The representative of the Ministry of Health did not answer the questions of Vedomosti.

Insurance in Russia is firmly established in the lives of people and organizations. Insurance protects the property and personal interests of various segments of society from risks and cataclysms. At the same time, disputes often arise in relations with insurance companies. If such problems arise, the best way out is to file a complaint with the central bank against the insurance company. At the word “Central Bank of the Russian Federation”, many get into a “stupor” and do not know how to communicate with this state body, what its functions are and what it has to do with insurance organizations. Let's try to understand this issue in more detail.

The Central Bank as a Supervisory Authority

Since insurance companies accumulate huge amounts and manage the money of policyholders, the state is obliged to monitor their activities to monitor the quality of services provided and the reliability of companies.

• insurance organizations compensate for damages to residents under emergency circumstances, exempting the state from this;
• policyholders must be confident in the reliability of insurers, as they give them their "hard-earned" money;
• insurance activities are quite profitable, therefore, the state receives taxes from their activities in the budget.
• endowment insurance increases the reliability of business, and the state is always interested in business development;
• mortgage insurance smoothing the peaks of crises.

In Russia, since 2010, the state has been pursuing an active policy of introducing new types of compulsory insurance in various fields.

Banks try to insure their every risk at the expense of their clients, which also increases the turnover of insurance companies every year, especially those controlled by banks. Often banks create insurance organizations to meet their needs and to keep profits in their financial group. Insurance activities are quite profitable, although at the highest level insurers often complain about their fate and ask for a legislative increase in tariffs for compulsory insurance. With such joint activities of the bank and the insurer, violations of insurance legislation are often possible in the form of imposing additional types of insurance. The client must remember that he can refuse the imposed services within a month. If the client has identified a violation of his rights, this can be resolved by writing a complaint against the insurer to the Central Bank.

State supervision in the insurance sector consists in monitoring compliance by insurers with the law, issuing licenses to carry out activities, as well as their suspension or withdrawal in case of violation of the law.

Since 2013, all insurance supervision powers, in accordance with the law and acts controlling insurance in Russia, have been transferred to the Central Bank of the Russian Federation. Within the Central Bank, these functions are performed by the Insurance Market Department under the Central Bank of the Russian Federation.

This department oversees:

1. Development of various rules, guidelines and other documents for the activities of insurers.
2. Compliance with insurance legislation by insurers.
3. The work of the guarantee fund, in which insurance organizations deduct part of insurance premiums to cover possible bankruptcy.
4. Compliance with insurance rates (which he himself calculates), etc.

Also, the competence of the insurance market department includes the resolution of conflicts between the parties to insurance relations, consideration of complaints on these conflicts and bringing the perpetrators to various forms of liability: from administrative to criminal. Sometimes other branches of the Central Bank are also involved in some types of control.

The main causes of disputes between the insurer and the insured

Insurers write complaints on completely different situations, but still the main part of the complaints concerns certain controversial issues.

• the insurer refuses or evades from concluding a compulsory insurance contract;
• the insurer does not comply with the term of insurance payments, violates the deadlines for responding to the insurer's requests;
• disputes over a discount for accident-free driving;
• the insurer imposes additional services when concluding OSAGO contracts, which increases the insurance burden of the insured;
• the insurer refuses to accept various documents from the insured: for example, applications for compensation for losses; refuses to issue documents on the insured event;
• the insurer refuses to pay the insurance indemnity or pays reduced amounts;
• the insurer raises insurance premiums;
• low-quality repairs were made according to OSAGO or CASCO.

For example, a few years ago, the imposition of additional insurance services was very common in insurance organizations when concluding compulsory insurance contracts.

Rosgosstrakh especially “suffered” from this. But thanks to complaints from citizens, the actions of regulatory authorities and court decisions, this situation was overcome.

Protecting your rights as an insured in court

If the Central Bank of the Russian Federation has considered your complaint and the result of consideration of the appeal does not suit you. If you think that this is wrong or does not comply with Russian law, then the regulator's response can be appealed in court.

Disputable points are also resolved in court, for the resolution of which the Central Bank of Russia does not have the authority. For example, how will the regulator be able to assess whether you have correctly calculated the amount of insurance compensation in case of a transport accident. This can only be assessed by an independent expert.

• write a pre-trial claim to comply with Russian judicial legislation, otherwise the court will return your application and you will have to start all over again;
• file a lawsuit on your own or with the help of a lawyer.

Other disputes may arise between the insured and the insurer, which sometimes cannot be resolved without the insurance market regulator. To protect your interests, you just need to complain to insurance companies.

Contacting the Central Bank of Russia for other insurance services

Usually the word "insurance" and the problems of insured events in our lives are associated with automobile OSAGO and CASCO, but compulsory and voluntary insurances are increasingly penetrating into our lives.

Much more often than before, policyholders apply for the conclusion of insurance contracts:

1. life.
2. Dwellings.
3. Health.
4. Voluntary health insurance.
5. Departure abroad.
6. Other different types of insurance.

Naturally, problems arise in these areas as well. The Central Bank of the Russian Federation also considers complaints regarding all types of insurance services. If the result does not suit you, then the courts are considering.

Registration, filing and sample of a complaint to the Central Bank of Russia against the actions of insurance organizations

There is no mandatory form for a complaint to the Central Bank of Russia to appeal against the actions of an insurance organization by Russian law.

• the name of the organization where the complaint is filed (in our case, the Central Bank);
• data of the insured who submits the complaint to the central bank: full name, address and telephone number (to receive a response), passport data; if the complaint is written by a legal entity, then its name, address and details;
• information about the insurer who violated your rights: name, address, details known to you;
• date, number of the concluded insurance contract, if the contract was concluded;
• essence of the complaint: how and by what means your rights as an insured were violated;
• what do you refer to to support your position: laws, regulations, results of judicial review, etc.;
• your requirements: what result do you want to see after considering the complaint;
• some additional information and documents that will help to consider the complaint in your favor: testimony of witnesses, audio recording, video recording and more.

It is absolutely necessary to attach copies of the documents to which you refer to the complaint. For example, a copy of the insurance contract or a written refusal of the insurance company to take some action (if you were given it, since insurance companies are required by law to give a written response to the policyholder's request).

1. To the territorial branch of the Central Bank of the Russian Federation in person or through a representative.
2. By registered mail to the Central Bank of the Russian Federation or a territorial office.
3. Through an electronic appeal on the website of the Central Bank of the Russian Federation.

Choose the shipping method that is convenient for you.

The term for consideration of a complaint in the Central Bank of Russia

Complaint to the Central Bank against the insurance company:

1. Considered much faster than litigation, which usually takes several months and often requires financial costs for legal support.
2. The progress of the complaint can be found online on the official website of the regulator or by phone.

The Central Bank of Russia considers complaints, like any state body, within a month from the date of receipt of the complaint. If consideration of the complaint requires any additional requests for documents from third parties, then, by decision of the commission, the consideration period may be extended.

Possible results of consideration of a complaint against an insurance company

If, when considering a complaint, the insurance market department at the Central Bank of the Russian Federation found violations of Russian insurance legislation in the actions of the insurer, then an order is issued to eliminate the violation of the law.

The insurance company is obliged to comply with the order within the period specified in the order.

• pay the amounts due to the client;
• pay the client fines, penalties and expenses incurred.

If the employees of the Central Bank found in the actions of the insurance organization the composition of an administrative offense or a criminal case, then the insurer is brought to administrative responsibility (the fines for violating the insurance legislation are considerable) or the police initiate a criminal case, the perpetrators are subject to dismissal.

If the insurance organization has not complied with the regulator's instructions within the specified period, the Central Bank has the right to suspend the license of the insurer. With numerous complaints and revealed violations, the Central Bank revokes the license to carry out insurance activities.

In any of the above cases, a written response is sent to the complainant.

If the result of the consideration of the complaint did not suit you, then you can contact other regulatory authorities (for example, the Union of Insurers) or the court.

Health care curators, the so-called insurance representatives of the third level, are starting to work in the compulsory medical insurance system. They will remind patients by phone about the doctor's recommendations after the medical examination and the need to take medication. There are already about 1.2 thousand such specialists in the staff of insurance companies. According to experts, the creation of the system is designed to improve the quality of medical care and increase the life expectancy of the population. However, for the full-fledged work of such curators, there should be many times more.

In addition to doctors, the health of the patient will now be monitored by employees of insurance companies of the compulsory medical insurance system, the so-called representatives of the third level. They started working in January of this year. As the Federal Compulsory Medical Insurance Fund (FFOMS) told Izvestia, there are now about 1.2 thousand specialists in the quality of medical care on the staff of organizations. Some of them are still in training.

Curators will analyze the health of a patient who has a compulsory medical insurance policy. They will monitor the implementation of the recommendations of doctors based on the results of the medical examination, by phone they will remind you of the need for tests, taking prescribed medications, and they can accompany the client to hospitalization. Separately, insurers will monitor the condition of chronic patients.

In the case of dispensary registration for a disease, the insurance representative works with each patient individually, taking into account his diagnosis, recommended requests for medical help, ensures compliance with the terms of hospitalization, interacts with the medical organization to possibly reduce the waiting period, - Izvestia was told in FFOMS.

Insurance representatives will also resolve conflicts between physicians and patients, resolve customer complaints, and, if necessary, conduct an examination of the quality of care. The FFOMS could not explain whether all insurance companies already have such specialists and when their services will be provided to patients in full.

The fund recalled that the institute of insurance representatives started operating in Russia in 2016. Now there are more than 7.5 thousand specialists of the first and second level in the country. They give clients advice on CHI services, remind them of the need to undergo medical examinations (by phone and via SMS). Third-level specialists are trained according to a program developed on the basis of the Department of Sociology of Medicine, Health Economics and Medical Insurance at Sechenov University.

General Director of the insurance company "Reso-Med" Yuri Demin confirmed that representatives of the third level are already starting to work with patients. But there is no clear regulation on how many such specialists should be in each company. So far, according to him, they proceed from such a scheme: one insurance representative of the first level - for 41 thousand insured persons, the second level - for 35 thousand, the third level - for 142 thousand.

With those companies that will not do this, the territorial CHI funds can terminate financial security agreements, - said Yuri Demin.

This is not only concern for citizens, but also a strategically important point, an emphasis on the prevention of disease detection. To seamlessly cure all non-communicable diseases, they must be detected at an early stage. Therefore, they are trying to involve Russians as fully as possible in regular checks of their health, the expert noted.

Natalia Aksenova, chairperson of the public council under the Ministry of Health, noted that 1,200 insurance representatives of the third level throughout the country are not enough, they will not be able to quickly respond to the requests of the insured and solve the problems that have arisen. Much more curators are needed, and they must be as competent as possible.

These should be professionals in their field, from among doctors, maybe even having a second higher education - a law. Information about these insurance representatives of the third level should be available to citizens, - explained Natalya Aksenova.

”, this year the Ministry of Health tripled the plan for medical examination. The examination must pass at least 63% of those who are entitled to it.