For purposes of this rule, "insurer" means property and
casualty insurers.
(1) An insurer
shall fully disclose to first-party claimants all pertinent benefits, coverages
or other provisions of a policy or contract under which a claim is
presented.
(2) Within 30 days after
receipt by the
insurer of properly executed proofs of loss, the first-party
property 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
documentation of the denial.
When there is a reasonable basis supported by specific
information available for review by the commissioner that the first-party
claimant has fraudulently caused or contributed to the loss, the insurer is
relieved from the requirements of this subrule. However, the claimant shall be
advised of the acceptance or denial of the claim within a reasonable time for
full investigation after receipt by the insurer of a properly executed proof of
loss.
(3) If the
insurer
needs more time to determine whether a first-party claim should be accepted or
denied, the
insurer shall so notify the first-party claimant within 30 days
after receipt of the proof of loss and give the reasons more time is needed. If
the investigation remains incomplete, the
insurer shall, 45 days from the
initial notification and every 45 days thereafter, send to the claimant a
letter setting forth the reasons additional time is needed for investigation.
When there is a reasonable basis supported by specific
information available for review by the commissioner for suspecting that the
first-party claimant has fraudulently caused or contributed to the loss, the
insurer is relieved from the requirements of this subrule. However, the
claimant shall be advised of the acceptance or denial of the claim by the
insurer within a reasonable time for full investigation after receipt by the
insurer of a properly executed proof of loss.
(4) 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.
(5) No insurer shall
make statements indicating that the rights of a third-party claimant may be
impaired if a form or release, other than a release to obtain medical records,
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 provision of a
statute of limitations.
(6) The
insurer shall affirm or deny liability on claims within a reasonable time and
shall tender payment within 30 days of affirmation of liability, if the amount
of the claim is determined and not in dispute. In claims where multiple
coverages are involved, payments that are not in dispute under one of the
coverages and where the payee is known should be tendered within 30 days if
such payment would terminate the insurer's known liability under that
coverage.
(7) No producer shall
conceal from a first-party claimant benefits, coverages or other provisions of
any insurance policy or insurance contract when such benefits, coverages or
other provisions are pertinent to a claim.
(8) A claim shall not be denied on the basis
of failure to exhibit property unless there is documentation of breach of the
policy provisions to exhibit or cooperate in the claim investigation.
(9) No insurer shall deny a claim based upon
the failure of a first-party claimant to give written notice of loss within a
specified time limit unless the written notice is a written policy condition.
An insurer may deny a claim if the claimant's failure to give written notice
after being requested to do so is so unreasonable as to constitute a breach of
the claimant's duty to cooperate with the insurer.
(10) No insurer shall indicate to a
first-party claimant on a payment draft, check or in any accompanying letter
that said payment is "final" or "a release" of any claim unless the policy
limit has been paid or there has been a compromise settlement agreed to by the
first-party claimant and the insurer as to coverage and amount payable under
the contract.
(11) No insurer shall
request or require any insured to submit to a polygraph examination unless
authorized under the applicable insurance contracts and state
law.
