Current through Register Vol. 48, No. 12, March 22, 2024
Column
A.
Identification Number. As noted, this refers to the identification number of
the complaint.
B. Reason Code.
Complaints are to be classified by the nature of the complaint within one of
the involved company's functions of underwriting, marketing and sales, claims,
policyholder service, and miscellaneous. The following is the classification
required for each function:
1) Underwriting
a) Company underwriting
b) Individual's application underwriting
(this refers to any complaint regarding misrepresentations or declarations in
the application for insurance that resulted in company action involved in the
complaint)
c)
Cancellation
d) Recission
e) Non-renewal
f) Premiums and rating
g) Delays
h) Refusal to insure
i) Miscellaneous (not covered by B(1)(a)
through (h))
j) Creditable coverage
re: Health Insurance Portability and Accountability Act (HIPAA)
k) Late enrollee (HIPAA)
l) Special enrollment (HIPAA)
m) Renewability (HIPAA)
2) Marketing and Sales
a) General advertising
b) Mass marketing advertising (advertising
that is essentially directed to reach more people than in a one-to-one
relationship)
c) Insurance producer
handling
d) Replacement
e) Delays
f) Alleged misleading statement or
misrepresentation
g) Miscellaneous
(not otherwise covered by this B(2))
3) Claims
a) Claims procedure
b) Delays
c) Unsatisfactory settlements
d) Natural disaster adjusting (hurricane,
flood or other situations that produce a large number of claims)
e) Unsatisfactory settlement offers
f) Denial of claim
g) Miscellaneous (not otherwise covered by
this B(3))
4)
Policyholder service
a) Failure to
respond
b) Delays
c) Return of premium
d) Miscellaneous (not covered by B(4)(a)
through (c))
e) Continuation -
State or federal
5)
Miscellaneous
C.Coverage
Code. Complaints are to be classified according to the line of insurance
involved, as follows:
1) Automobile -
Personal
2) Automobile -
Commercial
3) Homeowners -
Farmowners - Mobile or Manufactured Homeowners - Dwelling
4) Commercial Property
5) Inland Marine
6) Individual Life
7) Group Life
8) Annuities
9) Individual Health - Accident &
Sickness (including PPO)
10) Group
Health - Accident & Sickness (including PPO)
11) HMO individual or group
12) Limited Health Service Organizations
(LHSO)
13) Workers'
Compensation
14)
General/Professional liability
15)
Miscellaneous (not otherwise covered by this C)
D.Company Disposition After Complaint
Receipt. The complaint record shall note the disposition of the complaint. The
following examples are recommended, but are not intended to be required
language nor to exhaust the possibilities. These examples are taken from the
form used by the Department of Insurance.
1)
Corrective action was taken
a) Rate problem
resolved
b) Cancellation
withdrawn
c) Non-renewal
rescinded
d) Policy restored
(Life/A & H)
e) Policy
issued
f) Premium
refunded
g) Additional monies paid
(claims)
h) Coverage extended
(claims)
i) Claim
reopened
j) Claim settled
k) Cash surrender paid
l) Referral approved
m) Provider changed
2) No action was deemed necessary
a) Contract provisions
b) Questions of fact
c) Policy not in force
d) Cancellation upheld
e) Non-renewal upheld
f) Return premium correct
g) Insufficient information (from
complainant)
3)
Information was furnished to complainant
E. Date Received. This refers to the date the
complaint was received by the insurer.
F. Date Closed. This refers to the date on
which the complaint was disposed of by the insurer, whether by one action or a
series of actions.
G. Insurance
Department Complaint. Complaints are to be classified so as to indicate if the
origin of the complaint was from an insurance department.
H. State of Origin. The complaint record
shall note the state from which the complaint originated. Ordinarily, this will
be the state of residence of the complainant.
