New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 25 - OFFICE OF THE INSURANCE CLAIMS OMBUDSMAN
Subchapter 1 - GENERAL POWERS AND DUTIES
Section 11:25-1.1 - Purpose and scope
Universal Citation: NJ Admin Code 11:25-1.1
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The purpose of this subchapter is to establish procedures for the Insurance Claims Ombudsman to exercise his or her statutory authority to:
1. Investigate consumer complaints involving
policies of insurance, including the payment of claims;
2. Monitor the implementation of
17:23A-1 et seq. (policyholder's
personal information disclosure practices of regulated insurers);
3. Monitor the implementation of
17:29B-1 et seq. and 17B:30-1 et
seq. (consumer complaints regarding unfair methods of competition; unfair,
deceptive and discriminatory acts or practices by insurers);
4. Monitor the implementation of
17:35C-1 et seq. (Medicare
supplement health insurance policies; regulation of contract provisions and
required disclosure to consumers);
5. Investigate alleged violations of
17:35C-11 (use of false,
misleading, or fraudulent statements and advertising to sell Medicare
supplement insurance to consumers);
6. Respond to consumer inquiries, including,
but not limited to, those regarding policy terms and availability of
coverage;
7. Ensure that accurate
and understandable buyers' guides and rate comparisons are published and
disseminated to consumers where required by law, except those with respect to
health insurance coverages provided pursuant to
17B:27A-2 et seq. and 17B:27A-17
et seq.;
8. Review the conduct of
arbitrators appointed in accordance with the terms of a policy of insurance to
arbitrate disputes, except those arbitration proceedings arising out of
policies issued pursuant to
39:6A-1 et seq. or already subject
to the provisions of N.J.A.C. 11:22-1;
9. Investigate such other improper patterns
or practices as are deemed necessary and appropriate to the Office of Insurance
Claims Ombudsman; and
10. Review
disputes that are appealed by consumers after an internal appeals procedure
(N.J.A.C. 11:25-2) is conducted by life, property and casualty
insurers.
(b) This subchapter shall apply to all claims filed under a policy of insurance issued in accordance with 17:17-1, 39:6A-1 et seq., or any policy of life or health insurance issued in accordance with Title 17 or Title 17B of the New Jersey Statutes, except any dispute which may be or has been filed or adjudicated pursuant to 39:6A-5.1 and 39:6A-5.2 (PIP Alternate Dispute Resolution) shall not be subject to the Ombudsman's review.
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