Code of Massachusetts Regulations
452 CMR - DEPARTMENT OF INDUSTRIAL ACCIDENTS
Title 452 CMR 7.00 - Practices By Insurers
Section 7.04 - Questionable Claims Handling Techniques/Patterns of Unreasonably Controverting Claims
Current through Register 1531, September 27, 2024
(1) Pursuant to M.G.L. c. 23E, § 3(b)(8), except in the case of open cases active in the Division of Dispute Resolution, the Department's Division of Administration shall receive for investigation, on a form prescribed by the Department, written allegations of questionable claims handling techniques or patterns of unreasonably controverting claims by insurers, group self-insurers, self-insurers, third party administrators, employers, or other entities, including agents and brokers, handling workers' compensation claims.
(2) The Division of Administration shall conduct an investigation, and shall provide the party against whom the allegation is made an opportunity to respond in writing to the written allegations within 30 days. The findings of said investigation shall be reported to the Commissioner of Insurance, to the party making the allegation, and to the respondent party, except that when a written allegation involves a self-insured employer, a Department-certified vocational rehabilitation provider, or a Department-approved utilization review agent, the findings shall be forwarded to the Director of the Department or his or her designee rather than to the Commissioner of Insurance.
(3) Questionable claims handling techniques or patterns of unreasonably controverting claims shall include, but not be limited to, techniques or patterns of practice which involve the following:
(4) The submission of evidence of any questionable claims handling techniques or patterns of unreasonably controverting claims, including but not limited to, the techniques or patterns of practice set out in 452 CMR 7.04(3), may be sufficient to support a finding by the Division of Administration that an insurer, group self-insurer, third party administrator, or agent or broker has, or is, engaging in questionable claims handling techniques or patterns of unreasonably controverting claims. The Division of Administration shall refer its findings to the Commissioner of Insurance to undertake such enforcement, license revocation, and/or other actions as may be applicable by law.
(5) The submission of evidence of any questionable claims handling techniques or patterns of unreasonably controverting claims, including but not limited to, the techniques or patterns of practice set out in 452 CMR 7.04(3), may be sufficient to support a finding by the Division of Administration that a self-insurer, vocational rehabilitation provider, or utilization review agent has, or is, engaging in questionable claims handling techniques or patterns of unreasonably controverting claims. The Division of Administration shall refer its findings to the Director of the Department to undertake such enforcement, fine, license revocation, and/or other actions as may be applicable by law.