Current through Register Vol. 46, No. 12, March 20, 2024
(a) In any case where there is no dispute as
to coverage, it shall be the duty of every insurer to offer claimants, or their
authorized representatives, amounts which are fair and reasonable as shown by
its investigation of the claim, providing the amounts so offered are within
policy limits and in accordance with the policy provisions.
(b) Actual cash value, unless otherwise
specifically defined by law or policy, means the lesser of the amounts for
which the claimant can reasonably be expected to:
(1) repair the property to its condition
immediately prior to the loss; or
(2) replace it with an item substantially
identical to the item damaged. Such amount shall include all monies paid or
payable as sales taxes on the item repaired or replaced. This shall not be
construed to prevent an insurer from issuing a policy insuring against physical
damage to property, where the amount of damages to be paid in the event of a
total loss to the property is a specified dollar amount.
(c)
(1)
Within 15 business days after receipt by the insurer of a properly executed
proof of loss and receipt of all items, statements and forms which the insurer
requested from the claimant, the claimant, or the claimant's authorized
representative, shall be advised in writing of the acceptance or rejection of
the claim by the insurer. When the insurer suspects that the claim involves
arson, the foregoing 15 business days shall be read as 30 business days
pursuant to section
2601 of the Insurance Law.
(2) If the insurer needs more time to
determine whether the claim should be accepted or rejected, it shall so notify
the claimant, or the claimant's authorized representative, within 15 business
days after receipt of such proof of loss, or requested information. Such
notification shall include the reasons additional time is needed for
investigation. If the claim remains unsettled, unless the matter is in
litigation or arbitration, the insurer shall, 90 days from the date of the
initial letter setting forth the need for further time to investigate, and
every 90 days thereafter, send to the claimant, or the claimant's authorized
representative, a letter setting forth the reasons additional time is needed
for investigation. If the claim is accepted, in whole or in part, the claimant,
or the claimant's authorized representative, shall be advised in writing of the
amount offered. In any case where the claim is rejected, the insurer shall
notify the claimant, or the claimant's authorized representative, in writing,
of any applicable policy provision limiting the claimant's right to sue the
insurer.
(3)
(i) Notwithstanding paragraph (2) of this
subdivision, the provisions of this paragraph shall apply to any claim for
loss, damage, or liability for loss, damage, or injury, occurring from October
26, 2012 through November 15, 2012 in the counties of Bronx, Kings, Nassau, New
York, Orange, Queens, Richmond, Rockland, Suffolk or Westchester, including
their adjacent waters, with respect to:
(a)
loss of or damage to real property;
(b) loss of or damage to personal property;
or
(c) other liabilities for loss
of, damage to, or injury to persons or property.
(ii) If the insurer needs more time to
determine whether the claim should be accepted or rejected, it shall so notify
the claimant, or the claimant's authorized representative, in writing, within
15 business days after receipt of such proof of loss, or requested information.
Such notification shall include the reasons additional time is needed for
investigation and the anticipated date a determination on the claim will be
provided. If the claim remains unsettled, unless the matter is in litigation or
arbitration, the insurer shall, 30 days from the date of the initial letter
setting forth the need for further time to investigate, and every 30 days
thereafter, send to the claimant, or the claimant's authorized representative,
a letter setting forth the reasons additional time is needed for investigation
and the anticipated date a determination on the claim will be provided. If the
claim is accepted, in whole or in part, the claimant, or the claimant's
authorized representative, shall be advised in writing of the amount offered.
If the insurer rejects a claim subject to clause (i)(a) or (b) of this
paragraph, the insurer shall notify the claimant, or the claimant's authorized
representative, in writing, of any applicable policy provision limiting the
claimant's right to sue the insurer.
(iii) If an insurer has any claim subject to
this paragraph under which the claimant, or the claimant's authorized
representative, has not been advised in writing of the insurer's acceptance or
rejection of the claim within the time frames specified in paragraph (1) of
this subdivision, the insurer shall submit a report to the superintendent in a
form acceptable to the superintendent. The insurer shall submit the report each
week that the insurer has any such claims. The insurer shall submit the report
on the Tuesday of the week, except if that day is a holiday, then the report
shall be submitted on the next business day. For each such claim, the insurer
shall specify:
(a) the date the loss was
alleged to have occurred;
(b) the
date the claim was filed with the insurer;
(c) the date a properly executed proof of
loss and receipt of all items, statements and forms required by the insurer
were received by the insurer;
(d)
the alleged estimated amount of the loss;
(e) the reason given for the
extension;
(f) the anticipated date
a determination will be made on the claim provided to the claimant;
(g) how many extensions have been requested
on that claim; and
(h) the zip code
where the loss occurred.
(d) The company shall inform the claimant in
writing as soon as it is determined that there was no policy in force or that
it is disclaiming liability because of a breach of policy provisions by the
policyholder. The insurer must also explain its specific reasons for
disclaiming coverage.
(e) In any
case where there is no dispute as to one or more elements of a claim, payment
for such element(s) shall be made notwithstanding the existence of disputes as
to other elements of the claim where such payment can be made without prejudice
to either party.
(f) Every insurer
shall pay any amount finally agreed upon in settlement of all or part of any
claim not later than five business days from the receipt of such agreement by
the insurer, or from the date of the performance by the claimant of any
condition set by such agreement, whichever is later, except as provided in
section
331 of the Insurance Law as respects liens
by tax districts on fire insurance proceeds.
(g) Checks or drafts in payment of claims;
releases. No insurer shall issue a check or draft in payment of a first-party
claim or any element thereof, arising under any policy subject to this Part,
that contains any language or provision that expressly or impliedly states that
acceptance of such check or draft shall constitute a final settlement or
release of any or all future obligations arising out of the loss. No insurer
shall require execution of a release on a first- or third-party claim that is
broader than the scope of the settlement.
(h) Any notice rejecting any element of a
claim involving personal property insurance shall contain the identity and the
claims processing address of the insurer, the insured's policy number, the
claim number, and the following statement prominently set forth:
"Should you wish to take this matter up with the New York
State Department of Financial Services, you may file a complaint with the
department either on its website at
http://www.dfs.ny.gov/consumer/fileacomplaint.htm
or by writing to the Consumer Assistance Unit, New York State Department of
Financial Services, at: One State Street, New York, NY 10004; One Commerce
Plaza, Albany, NY 12257; 1399 Franklin Avenue, Garden City, NY 11530; or 535
Washington Street, Suite 305, Buffalo, NY 14203 ."