UNFAIR CLAIMS SETTLEMENT PRACTICES MODEL REGULATION

 

Section 1.  Authority

 

Section 4(9) of the Unfair Trade Practices Act prohibits insurers doing business in the state from engaging in unfair claims settlement practices and provides that if any insurer performs any of the acts or practices proscribed by that section with such frequency as to indicate a general business practice, then those acts shall constitute an unfair or deceptive act or practice in the business of insurance.

 

Section 2.  Scope

 

This regulation defines certain minimum standards which, if violated with such frequency as to indicate a general business practice, will be deemed to constitute unfair claims settlement practices.  This regulation applies to all persons and to all insurance policies and insurance contracts except policies of Workers’ Compensation insurance.  This regulation is not exclusive, and other acts, not herein specified, may also be deemed to be a violation of Section 4(9) of the Act.

 

Section 3.  Definitions

 

The definitions of “person” and of “insurance policy or insurance contract” contained in section 2 of the Unfair Trade Practices Act shall apply to this regulation and, in addition, where used in this regulation:

 

A.         "Agent" means any individual, corporation, association, partnership or other legal entity authorized to represent an insurer with respect to a claim;

 

B.            "Claimant" means either a first party claimant, a third party claimant, or both and includes the claimant's designated legal representative and includes a member of the claimant's immediate family designated by the claimant;

 

C.         "First party claimant" means an individual, corporation, association, partnership or other legal entity asserting a right to payment under an insurance policy or insurance contract arising out of the occurrence of the contingency or loss covered by such policy or contract;

 

D.         “Insurer” means a person licensed to issue or who issues any insurance policy or insurance contract in this State.

 

E.            "Investigation" means all activities of an insurer directly or indirectly related to the determination of liabilities under coverages afforded by an insurance policy or insurance contract;

 

F.            "Notification of claim" means any notification, whether in writing or other means acceptable under the terms of an insurance policy or insurance contract, to an insurer or its agent, by a claimant, which reasonably apprises the insurer of the facts pertinent to a claim;

 

G.         "Third party claimant" means any individual, corporation, association, partnership or other legal entity asserting a claim against any individual, corporation, association, partnership or other legal entity insured under an insurance policy or insurance contract of an insurer; and

 

H.            "Worker’s Compensation” includes, but is not limited to, Longshoremen’s and Harbor Workers’ Compensation.

 

Section 4.  File and Record Documentation

 

The insurer’s claim files shall be subject to examination by the (Commissioner) or by his duly appointed designees.  Such files shall contain all notes and work papers pertaining to the claim in such detail that pertinent events and the dates of such events can be reconstructed.

 

Section 5.  Misrepresentation of Policy Provisions

 

A.         No insurer shall fail to fully disclose to first party claimants all pertinent benefits, coverages or other provisions of an insurance policy or insurance contract under which a claim is presented.

 

B.         No agent shall conceal from first party claimants benefits, coverages or other provisions of any insurance policy or insurance contract when such benefits, coverages or other provisions are pertinent to a claim.

 

C.         No insurer shall deny a claim for failure to exhibit the property without proof of demand and unfounded refusal by a claimant to do so.

 

D.         No insurer shall, except where there is a time limit specified in the policy, make statements, written or otherwise, requiring a claimant to give written notice of loss or proof of loss within a specified time limit and which seek to relieve the company of its obligations if such a time limit is not complied with unless the failure to comply with such time limit prejudices the insurer’s rights.

 

E.         No insurer shall request a first party claimant to sin a release that extends beyond the subject matter that gave rise to the claim payment.

 

F.         No insurer shall issue checks or drafts in partial settlement of a loss or claim under a specific coverage which contain language which release the insurer or its insured from its total liability.

 

Section 6.  Failure to Acknowledge Pertinent Communications

 

A.         Every insurer, upon receiving notification of a claim shall, within ten working days, acknowledge the receipt of such notice unless payment is made within such period of time.  If an acknowledgement is made by means other than writing, an appropriate notation of such  acknowledgement shall be made in the claim file of the insurer and dated.  Notification given to an agent of an insurer shall be notification to the insurer.

 

B.         Every insurer, upon receipt of any inquiry from the insurance department respecting a claim shall, within fifteen working days of receipt of such inquiry, furnish the department with an adequate response to the inquiry.

 

C.         An appropriate reply shall be made within ten working days on all other pertinent communications from a claimant which reasonably suggest that a response is expected.

 

D.         Every insurer, upon receiving notification of claim, shall promptly provide necessary claim forms, instructions and reasonable assistance so that first party claimants can comply with the policy conditions and the insurer's reasonable requirements.  Compliance with this paragraph within ten working days of notification of a claim shall constitute compliance with Subsection A of this section.

 

Section 7.  Standards for Prompt Investigation of Claims

 

Every insurer shall complete investigation of a claim within thirty days after notification of claim, unless such investigation cannot reasonably be completed within such time.

 

Section 8.  Standards for Prompt, Fair and Equitable Settlements Applicable to All Insurers

 

A.         Within 15 working days after receipt by the insurer of properly executed proofs of loss, the first party claimant shall be advised of the acceptance or denial of the claim by the insurer.  No insurer shall deny a claim on the grounds of a specific policy provision, condition, or exclusion unless reference to such provision, condition, or exclusion is included in the denial.  The denial must be given to the claimant in writing and the claim file of the insurer shall contain a copy of the denial.

 

B.         If a claim is denied for reasons other than those described in paragraph (a) and is made by any other means than writing, an appropriate notation shall be made in the claim file of the insurer.

 

C.         If the insurer needs more time to determine whether a first party claim should be accepted or denied, it shall so notify the first party claimant within fifteen working days after receipt of the proofs of loss, giving the reasons more time is needed.  If the investigation remains incomplete, the insurer shall, forty-five days from the date of the initial notification and every forty-five days thereafter, send to such claimant a letter setting forth the reasons additional time is needed for investigation.

 

D.         Insurers shall not fail to settle first party claims on the basis that responsibility for payment should be assumed by others except as may otherwise be provided by policy provisions.

 

E.         Insurers shall not continue negotiations for settlement of a claim directly with a claimant who is neither an attorney nor represented by an attorney until the claimant’s rights may be affected by a statute of limitations or a policy or contract time limit, without giving the claimant written notice that the time limit may be expiring and may affect the claimant’s rights.  Such notice shall be given to first party claimants thirty days and to third party claimants sixty days before the date on which such time limit may expire.

 

F.         No insurer shall make statements which indicate that the rights of a third party claimant may be impaired if a form or release is not completed within a given period of time unless the statement is given for the purpose of notifying the third party claimant of the provisions of a statute of limitations.

 

G.         An insurer shall not attempt to settle a loss with a first party claimant on the basis of a cash settlement which is less than the amount the insurer would pay if repairs were made, other than in total loss situations, unless such amount is agreed to by the insured.

 

Section 9.            Standards for Prompt, Fair and Equitable Settlements Applicable to Automobile Insurance

 

A.         When the insurance policy provides for the adjustment and settlement of first party automobile total losses on the basis of actual cash value or replacement with another of like kind and quality, one of the following methods must apply:

 

(1)        The insurer may elect to offer a replacement automobile which is a specific comparable automobile available to the insured, with all applicable taxes, license fees and other fees incident to transfer of evidence of ownership of the automobile paid, at no cost other than any deductible provided in the policy.  The offer and any rejection thereof must be documented in the claim file.

 

(2)        The insurer may elect a cash settlement based upon the actual cost, less any deductible provided in the policy, to purchase a comparable automobile including all applicable taxes, license fees and other fees incident to transfer of evidence of ownership of a comparable automobile.  Such cost may be determined by

 

(a)        The cost of a comparable automobile in the local market area when a comparable automobile is available in the local market area.

 

 (b)       One of two or more quotations obtained by the insurer from two or more licensed dealers located within the local market area when a comparable automobile is not available in the local market area.

 

3.         When a first party automobile total loss is settled on a basis which deviates from the methods described in subsections (a)(1) and (a)(2) of this section, the deviation must be supported by documentation giving particulars of the automobile condition.  Any deductions from such cost, including deduction for salvage, must be measurable, discernible, itemized and specified as to dollar amount and shall be appropriate in amount.  The basis for such settlement shall be fully explained to the first party claimant.

 

B.         Where liability and damages are reasonably clear, insurers shall not recommend that third party claimants make claim under their own policies solely to avoid paying claims under such insurer’s insurance policy or insurance contract.

 

C.         Insurer shall not require a claimant to travel unreasonably either to inspect a replacement automobile, to obtain a repair estimate or to have the automobile repaired at a specific repair shop.

 

D.         Insurers shall, upon the claimant’s request, include the first party claimant’s deductible, if any, in subrogation demands.  Subrogation recoveries shall be shared on a proportionate basis with the first party claimant, unless the deductible amount has been otherwise recovered. No deduction for expenses can be made from the deductible recovery unless an outside attorney is retained to collect such recovery.  The deduction may then be for only a pro rata share of the allocated loss adjustment expense.

 

E.         If an insurer prepares an estimate of the cost of automobile repairs, such estimate shall be in an amount for which it may be reasonably expected the damage can be satisfactorily repaired.  The insurer shall give a copy of the estimate to the claimant and may furnish to the claimant the names of one or more conveniently located repair shops.

 

F.         When the amount claimed is reduced because of betterment or depreciation all information for such reduction shall be contained in the claim file.  Such deductions shall be itemized and specified as to dollar amount and shall be appropriate for the amount of deductions.

 

G.         When the insurer elects to repair and designates a specific repair shop for automobile repairs, the insurer shall cause the damaged automobile to be restored to its condition prior to the loss at no additional cost to the claimant other than as stated in the policy and within a reasonable period of time.

 

[[The insurer shall not use as a basis for cash settlement with a first party claimant an amount which is less than the amount which the insurer would pay if repairs were made, other than in total loss situations, unless such amount is agreed to by the insured.]]  Insurers shall include consideration of applicable taxes, license fees, and other fees incident to transfer of evidence of ownership in third party automobile total losses and shall have sufficient documentation relative to how the settlement was obtained in the claim file.  A measure of damages shall be applied which will compensate third party claimants for the reasonable loss sustained as the proximate result of the insured’s negligence.