28 Tex. Admin. Code § 21.2504 - Complaint Record; Required Elements; Explanation and Instructions

(a) Complaint record: general information. The complaint record provided for in this subchapter shall be maintained by all insurers. The complaint record is based on the Model Regulation for Complaint Records to be Maintained adopted by the National Association of Insurance Commissioners (NAIC), and incorporates the prescribed minimum information required to be maintained in a complaint record complying with all maintenance provisions of the NAIC Model regulation. The complaint record is intended and recommended to be maintained as a single, comprehensive record. The complaint record presented to the department at time of examination or in response to department request must indicate the total number of complaints received for the applicable time interval as set out in this subchapter.

(1) The complaint record may be maintained at the option of the insurer in either an electronic format or a hard-copy format.

(2) The format set out in § 21.2505 of this title (relating to Complaint Record Form) is preferred and recommended for both maintenance and presentation. Moreover, utilization of NAIC Complaint Database System Standard Complaint Data Form classification coding conventions for the classifications and categories set out in subsections (b)-(h) of this section, as applicable, is preferred as a maintenance and presentation option.

(3) If the complaint record is maintained in a format other than the recommended form or as a decentralized record, the insurer must nonetheless be capable of providing the department a complete complaint record upon examination or other departmental request. Subsections (b)-(i) of this section set out information items to be included in the complaint record and refer to the recommended documentary format.

(b) Complaint identification information. The complaint record must include, as indicated in Column (1) of the Complaint Record Form, entry of a unique complaint identifier, preferably numeric, assigned by the insurer to the underlying originally-submitted complaint. For any complaint involving an agent, the complaint record must also include a unique identifier, preferably numeric, for the placing or servicing agent.

(c) Function and reason categories for the complaint. The complaint record must include, as indicated in Column (2) of the Complaint Record Form, an entry for both the function code category, and the reason code category applicable to the complaint. Each complaint is to be classified hierarchically so that each is first assigned a function code category, followed by a reason code category. The function code categories set out in this subsection relate to particular kinds of company activities. The reason code categories relate to the more specific transactions entered into or actions taken by the insurer and contributing to the complaint. It is recommended but not required that the four-digit reason codes set out by the NAIC in its Complaint Database System Standard Complaint Data Form be utilized in maintenance of reasons for complaints addressed in this subsection. The function categories are set out with descriptive specificity in paragraphs (1)-(5) of this subsection, with particular reason categories similarly set out as subparagraphs within those paragraphs, as follows:

(1) Underwriting

(A) Company underwriting

(B) Individual application underwriting (applicable to complaints where misrepresentations or declarations in an application results in insurer action that is the subject of the complaint)

(C) Cancellation

(D) Rescission

(E) Nonrenewal

(F) Premiums and rating

(G) Delays

(H) Refusal to insure

(I) Miscellaneous (any reason not specified in subparagraphs (A)-(H) of this paragraph)

(2) Marketing and Sales

(A) General Advertising

(B) Mass marketing advertising (any advertising essentially directed to reach more people than in a one-to-one relationship)

(C) Agent handling

(D) Replacement

(E) Dividend illustration

(F) Delays

(G) Misleading statement or misrepresentation

(H) Miscellaneous (any reason not specified in subparagraphs (A)-(G) of this paragraph)

(3) Claims

(A) Claims procedure

(B) Delays

(C) Unsatisfactory settlements

(D) Natural disaster adjusting (situations producing a large number of claims)

(E) Unsatisfactory settlement offers

(F) Denial of claim

(G) Miscellaneous (any reason not specified in subparagraphs (A)-(F) of this paragraph)

(4) Policyholder service

(A) Failure to respond

(B) Delays

(C) Miscellaneous (any reason not specified in subparagraphs (A) or (B) of this paragraph)

(5) Miscellaneous

(d) Line type. The complaint record must include, as indicated in Column (3) of the Complaint Record Form, an entry which indicates the line of insurance involved, utilizing the classification categories set out in paragraphs (1)-(14) of this subsection. It is recommended but not required that the four-digit reason codes set out by the NAIC in its Complaint Database System Standard Complaint Data Form be utilized in maintenance of line type indication addressed in this subsection. The line type categories are as follows:

(1) Automobile

(2) Fire

(3) Homeowners--Farmowners

(4) Crop

(5) Inland Marine

(6) Individual Life

(7) Group Life

(8) Annuities

(9) Individual Health--Accident and Sickness

(10) Group Health--Accident and Sickness

(11) Workers' Compensation

(12) Liability Insurance other than Automobile

(13) Mobile Homeowners

(14) Miscellaneous (any line not specified in paragraphs (1)-(13) of this subsection)

(e) Company disposition after receipt. The complaint record must include, as indicated in Column (4) of the Complaint Record Form, an entry indicating manner of final disposition of the complaint. The department prefers and recommends, but does not require, that the disposition codes or reasons set out in paragraphs (1)-(15) of this subsection be utilized by insurers in categorizing the manner in which a complaint is disposed of or resolved. The department recommends use of such reason categories because, although the NAIC Model Regulation for Complaint Records to be Maintained does not include specific categories, the NAIC Complaints Database System includes such disposition categories, along with four-digit numeric identifiers, as standard complaint coding conventions. Although not intended to be exhaustive of all disposition descriptions, the recommended disposition reasons in paragraphs (1)-(15) of this subsection are as follows:

(1) Policy issued/restored

(2) Claim settled

(3) Additional claim payment made

(4) Refund of premium

(5) Advertising withdrawn/amended

(6) Underwriting practice resolved

(7) Cancellation notice withdrawn

(8) Nonrenewal notice rescinded

(9) Premium or rate problem resolved

(10) Question of fact

(11) Contract provision/legal issue

(12) Company position upheld

(13) Insufficient information

(14) Claim resolved through arbitration or mediation

(15) Other (Any disposition not addressed in paragraphs (1)-(14) of this subsection.)

(f) Date received. The complaint record must include, as indicated in Column (5) of the Complaint Record Form, entry of the date the complaint was received. The date received is the date the insurer originally received the complaint.

(g) Date closed. The complaint record must include, as indicated in Column (6) of the Complaint Record Form, entry of the date the complaint was closed. The date closed is the date on which the complaint was finally disposed of, either by a single action or by the final in series of actions as might be necessary for some complaints.

(h) Source of complaint. The complaint record must include, as indicated in Column (7) of the Complaint Record Form, an entry classifying origin of the complaint. At a minimum, the entry must clearly indicate any complaint originating from TDI or another insurance department. It is recommended but not required that the NAIC Complaints Database System standard complaint coding conventions for "complainant type" be utilized for classifying the origin of complaints other than those from insurance departments.

(i) State of origin. The complaint record must include, as indicated in Column (8) of the Complaint Record Form, an entry classifying origin of the complaint by state.

Notes

28 Tex. Admin. Code § 21.2504

The provisions of this §21.2504 adopted to be effective December 7, 1998, 23 TexReg 12398.