Current through Register Vol. 56, No. 18, September 16, 2024
(a) Upon the
request of a consumer, the Ombudsman may conduct a review of any disputed
insurance claim settlement where there is reasonable cause to believe that an
insurer has failed or refused to settle a claim in accordance with the
provisions of the policy or has engaged in any practice that may constitute a
violation of
17:23A-1 et seq., 17:29B-1 et
seq., 17:35C-1 et seq., 17B:30-1 et seq., or 17:35C-11; or
(b) Consumers seeking review in accordance
with (a) above shall file a complaint with the Ombudsman in any form, which
indicates that the complainant is seeking review of a disputed claim. All
complaints shall be sent to:
New Jersey Department of Banking and Insurance
Consumer Assistance
20 West State Street
PO Box 329
Trenton, NJ 08625-0329
Telephone: (609) 292-7272
Telefax: (609) 292-2431 or (609) 777-0508
Automated Hotline: 1-800-446-7467
E-mail: ombudsman@dobi.nj.gov
Electronic complaint submissions:
http://www.state.nj.us/dobi/consumer.htm
1. All complaints received by the Ombudsman
shall be entered into the data tracking system of the Consumer Assistance Unit
in the Office of Consumer Protection Services. The Ombudsman shall retain
complaints for further action, or refer them to the Consumer Assistance Unit in
the Office of Consumer Protection Services for disposition. The Consumer
Assistance Unit in the Office of Consumer Protection Services may likewise
refer matters to the Ombudsman.
2.
If the Ombudsman needs further information on any complaint, the office shall
notify the complainant of the additional information needed before any further
action may be taken.
3. A copy of
the filed complaint shall be sent promptly to the respondent together with a
transmittal letter that advises the respondent that an answer to the complaint
must be filed no more than 15 business days after the date of receipt of the
transmittal letter.
4. The
respondent may raise a general denial to the complainant's allegations and may
also raise such other legal, contractual or equitable defenses, which explain
or justify the actions of the respondent.
5. Thereafter, the complainant shall be
advised of the respondent's contentions and given an opportunity to rebut
within 15 business days of receipt of the notice.
6. When deemed appropriate, the Ombudsman may
extend all time limits mentioned in this subsection.
(c) At the discretion of the Ombudsman, an
investigation and hearing may be conducted in person and under oath.
1. In the conduct of an investigation, the
Ombudsman may, in his or her sole discretion:
i. Investigate whether the insurer's actions,
determinations and proceedings with respect to the claim were in accordance
with the law and the policy;
ii.
Make any necessary and appropriate inquiries of the insurer or any other
interested person to obtain such information as the Ombudsman deems necessary
to the investigation;
iii. Hold a
hearing on the disputed claim;
iv.
Inspect any books and records that relate to the claim; and
v. Issue subpoenas to compel the attendance
of any person at a specific time and place, as well as require the production
of any documents, books, records, papers, objects and other evidence deemed
necessary and relevant to the claim under investigation.
2. The Ombudsman may elect not to investigate
a complaint if it is determined that:
i. The
complaint is trivial, frivolous, vexatious or not made in good faith;
ii. The complaint has been too long delayed
to justify further investigation;
iii. The resources available, considering the
established priorities, are insufficient for an adequate
investigation;
iv. The matter
complained of is not within the investigatory authority of the Ombudsman;
or
v. The subject is already under
investigation by the Department or the Bureau of Fraud Deterrence.
