Ill. Admin. Code tit. 50, § 919.40 - Definitions/Explanations

Current through Register Vol. 46, No. 15, April 8, 2022

"Code" means the Illinois Insurance Code [215 ILCS 5 ].

"Company" means any licensee of the Department of Insurance, including health maintenance organizations.

"Days", for the purpose of this Part, means calendar days.

"Department" means the Illinois Department of Insurance.

"Director" means the Director of the Illinois Department of Insurance.

"Documentation" means all pertinent communications, transactions, notes and work papers. All such communications, transactions, notes and work papers shall be properly dated and compiled in sufficient detail in order to allow for the reconstruction of all pertinent events relative to each claim file. Documentation shall include but not be limited to bills, explanations of benefits and worksheets.

"First Party" means any individual, corporation, association, partnership, or other legal entity asserting a contractual right to payment under an insurance policy or insurance contract arising out of the contingency or loss covered by the policy or contract.

"Insured" means, for the purposes of life, accident and health insurance or other health care or service plans, the party named on a contract as the individual, corporation or association with legal rights to the benefits provided by the contract. This includes certificate holders or subscribers to a group contract and enrollees of a health maintenance organization, any other type of health care or service plans, or third party administrator. For purposes of property and casualty insurance, the party named on the contract is the insured.

"Non-Original Manufacturer" means any manufacturer other than the manufacturer of the original part.

"Notice of Availability of the Department of Insurance", as required by this Part, shall be no less informative than the following:

Part 919 of the Rules of the Illinois Department of Insurance requires that our company advise you that, if you wish to take this matter up with the Illinois Department of Insurance, it maintains a Consumer Division in Chicago at 122 S. Michigan Ave., 19th Floor, Chicago, Illinois 60603 and in Springfield at 320 West Washington Street, Springfield, Illinois 62767.

"Notification of Loss" means communication, as required by the policy or that is otherwise acceptable by the insurer, from a claimant or insured to the insurer that identifies the claimant or insured and indicates that a loss has occurred or is about to occur.

"Pertinent Communication", as used in Section 154.6(b) of the Code, means all correspondence, regardless of source or type, that is materially related to the handling of the claim.

"Policy", for the purpose of this Part, means a policy, certificate or contract issued to Illinois residents, including a certificate of enrollment into a health maintenance organization or any other type of health care or service plan.

"Private Passenger Automobile" means a vehicle insured under a policy of automobile insurance as defined in Section 143.13 of the Code.

"Prompt Investigation", as used in Section 154.6(c) of the Code , means all activities of the company related directly or indirectly to the determination of liability based on claims under the coverage afforded by the policy and shall be evidenced by a bonafide effort to communicate with all insureds and claimants when liability is reasonably clear within 21 working days after a notification of loss. Evidence of bonafide effort to communicate with insureds and claimants shall be maintained in the company's claim files.

"Reasonable Promptness", as used in Section 154.6(b) of the Code, means a maximum of 15 working days from receipt of communication from a claimant or insured.

"Replacement Crash Parts", for purposes of this Part, means sheet metal or synthetic parts, e.g., plastic, fiberglass, etc., that constitute the exterior of a motor vehicle, including inner and outer panels.

"Representative" means any person expressly authorized to act on behalf of the insurer and any employee of the insurer who acts or appears to act on behalf of the insurer in matters relating to claims, including but not limited to independent contractors while performing claim services at the direction of the company.

"Settlement of Claims", as used in Section 154.6(c) of the Code, shall pertain to all activities of the company or its representatives, relating directly or indirectly to the determination of the extent of liabilities due or potentially due under coverages afforded by the policy. Evidence of those activities shall be maintained in the company's claim files.

"Third Party" refers to any individual, corporation, association, partnership or other legal entity asserting a claim against any individual, corporation, partnership or other legal entity insured under a policy.

Notes

Ill. Admin. Code tit. 50, § 919.40

Amended at 26 Ill. Reg. 11915, effective July 22, 2002

Amended at 38 Ill. Reg. 15600, effective 7/2/2014

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