CHAPTER Ins 1000 CLAIM SETTLEMENT
Statutory Authority: RSA 400-A:15, I.
PART Ins 1001 CLAIM SETTLEMENT FOR ALL INSURERS,
EXCEPT PROPERTY AND CASUALTY
Ins 1001.01 Communications Time Limit.
(a) Every insurer, upon notice of a claim, shall
acknowledge the receipt of such notice in writing within 10 working days. This requirement of written acknowledgment
shall not preclude a speedier method of acknowledgment where the circumstances
warrant. Notification given to an agent
of an insurer shall be to the insurer if such agent notifies the claimant
within 5 working days that the agent is not notification to the insurer. If the notification is given to the agent of an insurer, such agent may
acknowledge receipt of such notice.
Unless otherwise provided by law or contract, notice to an agent of an
insurer shall not be notice authorized to receive notices of claims.
(b) Every insurer shall reply within 10 working
days to all claims communications from insureds, claimants, or authorized
representatives of either.
(c) Every
insurer, upon receipt of an inquiry from the insurance department, shall within
10 working days furnish the department with a complete and accurate written
response to the inquiry.
Source. #1900, eff 1-1-82;
ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss by #6999, eff 5-24-99,
EXPIRED: 5-24-07
New. #8900, eff 7-1-07, EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1001.02 Claims Settlement Time Limits.
(a) A complete decision regarding member payment
or coverage or denial shall be made by the insurer within 30 days of receipt of
any health insurance claim. In the event
of extenuating circumstances, if a complete coverage decision is not made
within 30 days, the insurer shall provide a written explanation to the member
claimant justifying such delay. This
provision shall not apply to provider-submitted claims for reimbursement for
services which have been provided to members.
(b) Unless otherwise provided by law, every
insurer shall establish procedures to commence an investigation of any claim
filed by an insured, claimant, or authorized representative of either within 5 working days upon receipt of notice of
loss. The procedures established shall
anticipate the seasonal changes in the volume of claims. Every insurer shall mail to every insured,
claimant, policyholder, or their authorized representative
a notification of all items, statements, or forms as well as blank copies
of all statements or forms which the insurer reasonably believes will be
required in the settlement of the claim.
(c) Unless otherwise provided by law, within 10
working days after acknowledgment of the receipt of a notice of a claim from the insured, claimant, or
authorized representative of either, the insurer shall advise the insured, claimant,
or authorized representative of either in writing of the acceptance or
rejection of the claim. If the insurer
needs more time to determine whether the claim should be accepted or rejected,
the insurer shall so notify the insured, claimant, or authorized
representative of either within 10 working days after acknowledgement of the
loss and provide the reasons for the delay.
(d) The insurer shall within 30 days from the
date of the letter setting forth a need for further time and every 30 days thereafter,
send to the insured, claimant, or authorized representative of either a letter
setting forth the reasons for the delay in the claim settlement, unless the
insured, claimant, or authorized representative otherwise agrees.
(e) An insurer shall not justify a delay in
processing or paying a claim on the grounds of suspected fraud unless the insurer has notified the
department and has provided the department with specific reasons to support its
suspicions.
(f) Whenever
the insurer denies a claim on the basis of no coverage
or the amount of loss is below the deductible, the insurer shall inform the
insured in writing the reason for the denial and include the department’s
toll-free telephone number.
(g) Any letter setting forth the need for further
time after the first 30-day period shall contain the following statement:
"We will, of course, be available to
you to discuss the position we have taken and answer your questions. You may reach us by calling the customer
service number located in this notice or the number on the back of your member
identification card, if you have one.
If you have been
unable to resolve your concern and are a resident of New Hampshire or have a
New Hampshire issued policy, you
may take this matter up with the
New Hampshire insurance department, as it maintains a service division to investigate
complaints at 21 South Fruit Street, Suite 14, Concord, NH, 0330l. The New Hampshire insurance department can be
reached, toll-free, by dialing 1-800-852-3416.”
(h) Unless otherwise provided by law, every
insurer shall pay any amount finally agreed upon in settlement of all or part
of a claim not later than 5 working days from the date of such agreement or
from the date of the performance by the insured, claimant, or authorized
representative of either of all conditions set forth by such agreement.
(i) An insurer shall
not request of a claimant or insured a waiver of insurer obligations under Ins 1000, except to request a waiver of the 30 day delay
letter provision of this rule. This
waiver shall be in writing and signed by the insured or claimant. The signed waiver shall be retained in the
claim file.
Source.
#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss
by #5649, eff 7-1-93; ss by #6999, eff 5-24-99, EXPIRED: 5-24-07
New. #8900, eff 7-1-07, EXPIRED: 10-26-15
New. #10962, eff 10-26-15; ss by #13173, eff 4-26-21
Ins 1001.03 Additional
Information Required in Accepting or Rejecting Claims.
(a) If a claim is denied in whole or in part the
insured, claimant or authorized representative of
either shall be given the reason for the denial. In any case where coverage is denied the
insurer shall notify the insured, claimant, or authorized representative of
either of the applicable policy provision upon which denial is based.
(b) Statements setting forth benefits included
within claim payments shall be in writing and in sufficient detail so that the
insured, claimant, or authorized representative of either can reasonably
understand the benefits included within the claim payment.
Source. #1900, eff 1-1-82;
ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss by #6999, eff 5-24-99,
EXPIRED: 5-24-07
New. #8900, eff
7-1-07 (from Ins 1001.04), EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1001.04 Undisputed Amounts. In any case
where there is no dispute as to one or more elements of the claim, an offer of
settlement for such undisputed elements shall be made without prejudice to
either party notwithstanding the existence of disputes as to other elements of
the claim.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss
by #5649, eff 7-1-93; ss and moved by #6999, eff 5-24-99 (from Ins 1001.05), EXPIRED: 5-24-07
New. #8900, eff
7-1-07 (from Ins 1001.05), EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1001.05 Required Notice of
Insurance Department. Any notice rejecting a claim in whole or in
part shall contain the following statement:
"We will, of course, be available to
you to discuss the position we have taken and answer your questions. You may reach us by calling the customer
service number located in this notice or the number on the back of your member
identification card, if you have one.
If you have been
unable to resolve your concern and are a resident of New Hampshire or have a
New Hampshire issued policy, you
may take this matter up with the
New Hampshire insurance department, it maintains a service division to investigate complaints at 21 South Fruit
Street, Suite 14, Concord, NH, 0330l.
The New Hampshire insurance department can be reached, toll-free, by
dialing 1-800-852-3416.”
Source.
#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss
and moved by #6999, eff 5-24-99 (from Ins 1001.06) ),
EXPIRED: 5-24-07
New. #8900, eff
7-1-07 (from Ins 1001.06), EXPIRED: 7-1-15
New. #10962, eff 10-26-15; ss by #13173, eff 4-26-21
Ins 1001.06 Advance Payments. No insurer
shall refuse to grant advance payments on a claim because the claimant, insured or authorized
representative of either has retained an attorney for the purpose of
facilitating recovery on his behalf.
Source. #1900, eff 1-1-82; ss by #4287, eff 7-1-87;
ss by #5649, eff 7-1-93; ss and moved by #6999, eff 5-24-99 (from Ins 1001.07) ), EXPIRED: 5-24-07
New. #8900, eff
7-1-07 (from Ins 1001.07), EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1001.07 Physician's Examination. Unless
otherwise provided by law, when a disability benefits claim has been accepted by an insurer under either an
individual accident and health policy or group policy, the insurer shall not
require additional reports from the insured's or beneficiary's physician to
substantiate disability which has already been established by a prior report.
Source.
#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss
and moved by #6999, eff 5-24-99 (from Ins 1001.08),
EXPIRED: 5-24-07
New. #8900, eff
7-1-07 (from Ins 1001.08), EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1001.08 Insurers Use of Unlicensed Adjusters
Prohibited. No insurer shall employ or otherwise utilize the
services of an adjuster unless that adjuster has complied with all the
appropriate licensing provisions of RSA 402-B or has been granted a temporary
license pursuant to RSA 402-B:11.
However, any claim adjusted to the satisfaction of an insurer and the
claimant by an unlicensed adjuster shall bind the insurer.
Source.
#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss
and moved by #6999, eff 5-24-99 (from Ins 1001.09),
EXPIRED: 5-24-07
New. #8900, eff
7-1-07 (formerly Ins 1001.13), EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1001.09 Telephone Communications
With Claims Department. Every insurer shall provide telephone
facilities whereby the insured, claimant, or authorized representative of
either can, without expense, contact the company claims office handling the particular claim. If
the company has no claims office located in
Notice of the fact that free telephone service is
available along with the appropriate phone number shall be indicated on company
claims forms.
Source.
#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss
and moved by #6999, eff 5-24-99 (from Ins 1001.10),
EXPIRED: 5-24-07
New. #8900, eff
7-1-07 (formerly Ins 1001.14), EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1001.10 Other Insurer
Responsibilities.
(a) If, under the provisions of RSA 417:4,
XV(a)(12), the insured fails or refuses to submit a report of the loss to the insurer, this shall be
considered to be a request by the insured not to pay the claim.
(b) The
insurer shall adjust all claims
in accordance with the provisions of the
Source.
#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss
and moved by #6999, eff 5-24-99 (from Ins 1001.11),
EXPIRED: 5-24-07
New. #8900, eff 7-1-07), EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1001.11 Penalty. Any insurer or
representative thereof who shall knowingly violate any provision of this part
shall be subject to the
provisions of RSA 400-A;15, III.
Source.
#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss
and moved by #6999, eff 5-24-99 (from Ins 1001.12),
EXPIRED: 5-24-07
New. #8900, eff
7-1-07 (formerly Ins 1001.16), EXPIRED: 7-1-15
New. #10962, eff 10-26-15
PART Ins 1002 CLAIM SETTLEMENT FOR PROPERTY &
CASUALTY INSURANCE
Statutory Authority: RSA
400-A:15,
Ins 1002.01 Purpose
and Scope.
(a)
The purpose of this part, unless otherwise provided by law, is to
establish claim settlement standards for all property and casualty insurance,
except workers' compensation and policies for large commercial policyholders as
defined in RSA 412:3, XI.
(b)
This part shall apply to all claims on property
and casualty insurance policies written on any combination of risks or
operations located in this state under the provisions of RSA 401:1, I, II, V,
VII, and VIII and any miscellaneous insurance under RSA 401:1-a that is
designated by the commissioner to be regulated under RSA 412.
Source. #8900, eff 7-1-07,
EXPIRED: 7-1-15
New. #10962, eff 10-26-15; ss by #13173, eff 4-26-21
Ins 1002.02 Definitions.
(a) "Claim
file" means the complete and specific claim file record of events and
dates maintained to show clearly the inception,
handling, and disposition of each claim.
(b)
"Claimant" means any
person who sustains bodily injury or property damage and who asserts a right to
recover for damages against an insured. The term "claimant" includes
the claimant's authorized representative acting on behalf of the claimant.
(c)
"Communications" means all correspondence and contact(s),
regardless of source or type, that is materially related to the handling of the
claim.
(d)
"Documentation" means all communications, transactions,
notes, work papers, claim forms, bills, statement of loss and other similar
materials relative to the claim.
(e) "Fair
market value" means the price at which an asset would change hands between
a willing buyer and a willing seller when neither is under compulsion to act and both have knowledge of all facts relevant to the
sale.
(f) "Independent
repair shop or facility" means any entity that:
(1) Provides automobile repair services; and
(2) Has no arrangement with respect to repair
prices or services with the insurer making a payment for settlement of the
damaged motor vehicle; but which might have arrangements with respect to repair
prices or services with other insurers.
(g)
"Insured" means, for the purposes of this rule only, a person
or persons who are included in the definition of an insured as set forth in the
insurance policy. The term
"insured" includes the insured's authorized representative acting on
behalf of the insured.
(h)
"Investigation" means the initial contact or documented
attempted contact with the insured or claimant and all activities of
an insurer directly or indirectly related to the determination of liabilities
under coverages afforded by an insurance policy.
(i) "Local market area" means a maximum
distance of 75 miles surrounding the area where the motor vehicle is principally
garaged and not limited to the geographic boundaries of the state of
(j) "Motor
vehicle" means motor vehicle as defined in RSA 259:60, III.
(k) "Notice of
a claim" means any notification, whether in writing or other means
acceptable under the terms of an insurance policy, to an insurer or its
appointed producer, by an insured or claimant, that apprises the insurer of the
facts pertinent to a claim.
(l) "Uninsured
motor vehicle" means a motor vehicle that is:
(1) Not insured under any insurance policy;
(2) An insured motor vehicle for which the
insurer is unable to make payment within the insured liability limits due to
insolvency; or
(3) An insured motor vehicle that at the time of
the accident had limits of liability insurance that were lower than the minimum
limits required for a motor vehicle liability policy pursuant to applicable
law.
Source. #8900, eff 7-1-07, EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1002.03 Computation of Time.
(a) Unless
otherwise specified, all time
periods referenced in this part shall be calendar days.
(b) Computation of any period of time referred to
in this part shall begin with the day after the action which sets the time period in motion,
and shall include the last day of the period so computed.
(c) If the last day of the period so computed
falls on a Saturday, Sunday or legal holiday, then the
time period shall be extended to
include the first business day following the Saturday, Sunday, or legal
holiday.
Source. #8900, eff 7-1-07, EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1002.04 Communications Time Limit.
(a) Notice of a
claim given by an insured or claimant to an insurer’s appointed producer shall
be considered notification to the insurer, unless:
(1) Otherwise provided by law or the policy; or
(2) The appointed producer notifies the insured
or claimant within 5 working days of receipt of notice of a claim that the
appointed producer is not authorized to receive notices of claims.
(b) Every insurer shall reply in no later than 10
working days to all claims communications from insureds or claimants. Receipt of documentation or information by an
insurer that was requested of the insured or claimant is a communication subject to response under this section.
(c) Every insurer,
upon receipt of an inquiry from the insurance department, shall within 10 working days furnish the department
with a complete and accurate written response to the inquiry.
Source. #8900, eff 7-1-07, EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1002.05 Claims Settlement Time
Limits.
(a) Unless otherwise
provided by law, every insurer shall establish procedures to:
(1) Commence an investigation of any notice of a
claim filed by an insured or claimant not later than 5 working days from
receipt of the notice of a claim; and
(2) Anticipate the seasonal changes in the volume
of claims in order to comply with this section.
(b) Every insurer,
upon receipt of notice of a claim, shall acknowledge the receipt of such notice
to the insured or claimant, within 10 working days, as follows:
(1) By written correspondence, including
facsimile or e-mail if acceptable to both parties; or
(2) By telephone or face-to-face communication if
the insurer provides the insured or claimant with the toll
free telephone number of the insurer's claims office handling the
claim. Thereafter, should the insured or
claimant request a written acknowledgment, the insurer shall provide written
acknowledgment within 5 working days from the request of the insured or
claimant.
(c) Unless otherwise
provided by law, within 30 days from the receipt of the notice of claim, the
insurer shall make a complete decision regarding coverage, acceptance, denial,
or payment of a claim and communicate this to the insured or claimant with the
following exceptions:
(1) If a decision cannot be made because the
insurer needs more time to make a decision, the insurer shall provide the
insured or claimant, in writing, a delay letter setting forth the specific
factual or legal reasons that the insurer needs more time to determine whether
the claim will be covered, accepted, paid, or denied;
(2) The insurer shall, within 30 days from the
date of the delay letter in (c)(1) above, and every 30 days thereafter, send a
letter setting forth the specific factual or legal reasons for the continued
delay in the claim settlement process;
(3) If the reason the claim remains open is that
the insurer is waiting for documentation or information requested of the
insured or claimant, then the insurer shall send a letter to the insured or
claimant requesting the particular documentation or information necessary to
accept, pay, or deny the claim, but shall not be required to send the delay
letter(s) to the insured or claimant as required in (c)(1) or (c) (2) above;
and
(4) If either party has filed suit, and the
settlement of the claim is being litigated in a court of law, the delay letter
in (c)(1) or (c)(2) above shall not be required.
(d) Unless otherwise
provided by law or court order, every insurer shall pay all or part of the
claim:
(1) Within 5 working days from date of agreement
with an insured or claimant; or
(2) Within 5 working days after receipt from the
insured or claimant, of documentation needed to process the claim for payment
as requested by the insurer.
(e) In any claim in
which the insurer cannot make a decision within 5
working days from the date of agreement or of receipt of the requested
documentation, the insurer shall send a delay letter to the insured or claimant
explaining the reasons for the delay in the claim settlement process.
(f) The insurer
shall, within 30 days from the date of the delay letter in (e) above, and every
30 days thereafter, send a letter setting forth the specific reasons for the
continued delay in the claim settlement process.
(g) When the reason
for delay is suspected fraud a delay letter issued pursuant to (c) or (d) above
shall be deemed sufficient if it indicates that the reason for the delay is
that further investigation is needed to determine the validity of the claim.
(h) Whenever the
insurer denies a claim, in whole or in part, including on the
basis of no coverage or that the amount of the loss is below the
deductible, or issues a reservation of rights letter, or when sending a second
or subsequent delay letter(s) as provided in (c)(2) and (f) above, the insurer
shall include the following statement in at least 12-point font bold type:
“We will, of course, be
available to you to discuss the position we have taken. You may reach us at
(insurance company toll free telephone number).
If you are a New Hampshire resident; if your policy insures property
located in New Hampshire; or if you have been injured/your property has been
damaged by a New Hampshire resident and you wish to take this matter up with
the New Hampshire Insurance Department, it maintains a consumer services
division to assist consumers with complaints at 21 South Fruit Street, Suite
14, Concord, NH, 03301. The New
Hampshire Insurance Department can be reached, toll free, by dialing
1-800-852-3416.
(i) An insurer shall not request of an insured or
claimant a waiver of the insurer's obligations under this part, except to
request a waiver of the 30 day delay letter provision
of (c)(2) and (f) above. The waiver
shall be in writing and signed by the insured or claimant. The signed waiver shall be retained in the
claim file.
Source. #8900, eff 7-1-07,
EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1002.06 Additional Information
Required in Accepting or Denying Claims.
(a) In addition to
the provisions of Ins 1002.05, if a claim is denied in whole or in part, the
insured or claimant shall be given a written notice of the reason for the
denial and any applicable policy provision upon which denial is based,
provided, however, that if the reason for the denial is fraud, the notification
shall be deemed sufficient if it provides a general statement explaining that
the damage did not occur in the manner reported by the insured and/or claimant.
(b) Every insurer
shall provide with each claim payment, either on the check, draft or in a
letter, the reason for the payment and the date of loss, for example,
“collision payment for your accident on (date), homeowner contents payment for
your fire loss on (date) or property damage loss to your motor vehicle as the
result of an accident on (date).”
Source. #8900, eff 7-1-07, EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1002.07 Undisputed
Amounts. In any case where there is no dispute as to
one or more elements of the claim, an offer of settlement for such undisputed
elements shall be made without prejudice to either party notwithstanding the
existence of disputes as to other elements of the claim.
Source. #8900, eff 7-1-07, EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1002.08 Claims
Payments.
(a) No insurer shall refuse to grant advance
payments on a claim because the insured or claimant has retained an attorney
for the purpose of facilitating recovery on his or her behalf.
(b) The form of payment of a claim shall allow
the claimant or insured ready access to claim funds and comply with one of the
following methods:
(1) Delivery of
payment by paper check or draft to the insured or claimant;
(2) With the prior verifiable authorization of the
insured or claimant, direct deposit to a claimant's or insured's financial
account; or
(3) With the
prior verifiable authorization of the insured or claimant, delivery of a debit
card, bank card, or other similar card, procured by arrangement between the
insurer and financial institution, whereby the claim payment to the consumer is
transferred from the insurer to the financial institution and held in an
account at the financial institution, provided:
a. Prior to
securing the verifiable authorization of the insured or claimant for payment by
such card, the insurer shall provide a written disclosure including:
1. All options for withdrawal of funds; and
2. An itemized list of any transaction or other fees or charges that
may be assessed to the insured or claimant using the card, including those by
third parties;
b. The contract
between the insurer and financial institution shall ensure that the insured or
claimant will receive written advance notice of any change to the terms and
conditions of the card until such time as the claimant or insured has expended
all funds on the card;
c.
Authorization to receive claim payments by one of the methods set out in
(b)(1), (b)(2) or (b)(3) shall be established for each claim at or after the
time of the claim, and the selection of that method of payment shall not
prohibit the insured or claimant from changing the method of payment for future
claim payments arising from the same claim nor shall it bind the insured or
claimant to selection of the same method of payment for future claims;
d. The card:
1. Shall permit
the claimant or insured at least one opportunity to withdraw the full amount
provided on the card without charge; or
2. If the card
does not provide for at least one opportunity to withdraw the full amount
without charge as described in d.1. above, the insurer shall:
(i) Obtain an express written waiver from the
insured or claimant of the right to a single, free opportunity to withdraw the
card funds; or
(ii) Upon the
request of the insured or claimant, send the consumer without charge, by
overnight delivery, a check for the lesser of:
i. The full
amount issued on the card; or
ii. The
remaining balance;
e. Upon
delivery of the card the insurer shall provide the insured or claimant:
1. A written
statement confirming the amount available on the card as issued, to include
information provided on the card itself indicating the amount available on the
card as issued; or
2. A toll free
number and secure internet site where the consumer can confirm the amount available
on the card as issued; and
f. If the
insured or claimant has not fully withdrawn or expended all funds in the card
account:
1. Prior to the
expiration of the card, a replacement card shall be issued at no cost to the
insured or claimant; or
2. Upon the
expiration of the card, any remaining funds shall be transferred to the
consumer using the methods described in (b)(1) or (2) of this paragraph.
Source. #8900, eff 7-1-07; ss by #10210, eff 12-1-12; ss by #10962, eff
10-26-15
Ins 1002.09 Value
of Total Losses – Other than Motor Vehicle. When the insured's or claimant's property has been determined to be a
total loss, and there is no dispute concerning liability or coverage, and the
provisions of RSA 407:11 do not apply, insurers attempting to establish the
value of the property shall:
(a) Value the property in the community where the total loss
property is located;
(b) Be prohibited from using
arbitrary methods to establish the value of the property that do not take into
consideration the specific
characteristics of the property, however, this shall
not preclude the insurer from making an offer of settlement on property based
upon the fair market value of like kind and quality property wherever situated.
(c) Consider as an element of
damages additional costs incurred in purchasing and shipping the property.
(d) Comply with Ins
1002.18 for every total loss settlement made or offered by the insurer to
replace lost or damaged jewelry, watches, precious, or
semi-precious stones, under applicable property insurance.
Source. #8900, eff 7-1-07; amd by #9495, eff
6-29-09; ss by #10962, eff 10-26-15
Ins 1002.10 Insurers
Use of Unlicensed Adjusters Prohibited. No insurer shall employ or
otherwise utilize the services of an adjuster unless that adjuster has complied
with all the appropriate licensing provisions of RSA 402-B or has been granted
a temporary license pursuant to RSA 402-B:11, however, any claim adjusted to
the satisfaction of an insurer and the insured or claimant by an unlicensed
adjuster shall bind the insurer.
Source. #8900, eff 7-1-07, EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1002.11 Communications
With Claims Department. To facilitate communication, every insurer
shall provide a toll-free telephone number on all forms or correspondence, and
if it chooses to do so, a facsimile number and/or e-mail address whereby the
insured or claimant can contact the company claims office, independent
adjuster, or appraiser handling the particular claim.
Source. #8900, eff 7-1-07, EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1002.12 Other Insurer
Responsibilities.
(a) Prior to
concluding that there is no coverage for the loss as a result
of the insured's failure to comply with any obligation
imposed on the insured under the policy, the insurer shall:
(1) Establish that the breach was a material
breach that excuses the insurer from performance under the insurance policy;
and
(2) Document the basis for concluding that the
breach is material in the claim file.
(b) An insurer shall
not refuse to make an evaluation of the insured's liability in any claim
because the insured requests that the insurer not make a claim payment for a
reported loss.
Source. #8900, eff 7-1-07,
EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1002.13 Loss of Use. In all motor vehicle property damage
liability claims when liability has become clear the insurer shall immediately
inform the claimant that coverage exists for the rental of a motor vehicle that
is of like kind and quality for the time period
necessary for repair, provided however that the insurer:
(a) Not be required
to provide coverage for that portion of the motor vehicle rental that the
insurer establishes is required due to an unreasonable delay in the repair
caused by the direct action or inaction of the claimant.
(b) Document the
basis for the finding of unreasonable delay pursuant to (a) above in the claim
file.
(c) Be able to
deduct the costs that would have been incurred in the operation of the
claimant's own motor vehicle from the total costs of renting and operating the
rented motor vehicle. If the claimant
does not have insurance coverage as required by the rental company, the insurer
shall pay the reasonable cost of the required coverage.
(d) Specifically
document the claim file with evidence to show that a rental was offered to the
claimant.
Source. #8900, eff 7-1-07, EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1002.14 Estimates. The
insured or claimant shall only be responsible for the cost of one damage
estimate for motor vehicle property damage liability and collision and
comprehensive claims. The insurer shall
be responsible for any charge incurred by the insured or claimant for any
subsequent damage estimates required by the insurer.
Source. #8900, eff 7-1-07, EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins
1002.15
Determining Amount of Motor
Vehicle Total Loss Claims.
(a)
In adjusting motor vehicle total loss property damage liability and
collision and comprehensive damage claims for actual cash value,
insurers shall determine total losses
consistent with the RSA 261:22, VI standards and settlements based upon the
motor vehicle’s fair market value using one of the following methods:
(1) The fair market value derived from the application
of a methodology that the department accepts as a statistically valid method of
establishing fair market value in the local market area; or
(2) The fair market value derived from documented
sales costs of no fewer than 2 motor vehicles of the same make, model, and year
as the total loss motor vehicle that have occurred within the previous 90 days
within the local market area. If documented sales costs information of
a motor vehicle of the same make, model, and year as the total loss motor
vehicle is unavailable, then the insurer shall use:
a. Documented sales costs of no fewer than 2
motor vehicles of like, kind, and quality that have occurred within the previous
90 days within the local market area; or
b. An average sales price derived from written
quotations for a motor vehicle that is the same make, model, and year as the total loss motor vehicle, obtained
by the insurer from at least 2 different licensed dealerships located within
the local market area, that engage in the buying and selling of motor vehicles
of like kind and quality in the ordinary
course of their
business.
(b) The following
deviations from the valuation methods in (a)(1) through (a)(2) shall be
permitted:
(1) For construction equipment as defined in RSA
259:42 and commercial motor vehicles as defined in RSA 259:12-e,
data may be collected from outside the local market area but only to the extent
necessary to obtain sufficient data as required in (a)(1) through (a)(2) above;
and
(2) If the insurer can demonstrate that the motor
vehicle is a make or model vehicle not customarily found in the local market
area, data may be collected from outside the local market area but only to the
extent necessary to obtain sufficient data as required in (a)(1) through (a)(2)
above.
(c)
If the insured or claimant disagrees with the value derived from (a)
through (b) above and can demonstrate that disagreement by presenting to the
insurer, within 20 days of receipt of the settlement payment, evidence from 2 reliable sources that the motor vehicle would have a higher fair
market value in the local market area or deviation under (b) than the
settlement payment, then the insurer shall recalculate a new fair market value
considering this reliable evidence in determining a revised total loss
settlement. Reliable evidence shall be
limited to the sources listed in (a)(2) or deviation under (b). However, the reliable evidence right of the
insured or claimant shall not apply if the insurer included in its documentation at the time
of settlement a written notification of the availability and location in the
local market area of a specified and comparable vehicle of the same manufacturer, same year, similar body style, and similar options, in as good or
better condition as the total loss vehicle, which could have been purchased for
an amount equal or less than the fair market value
of the total loss vehicle as determined by the insurer. The documentation shall include the vehicle
identification number.
(d) In conjunction
with a total loss settlement offer, the insurer shall provide to the insured or
claimant a report which explains the basis for the valuation underlying the
offer.
(e) Fair market value as determined in (a)(1)
through (2) above shall be adjusted to reflect motor vehicle condition,
mileage, accessories, and options. Insurers shall consider usual and customary
documentary preparation fees in determining fair market value.
(f) The insured or
claimant has the right to a rental for at least the applicable insurance policy
period for insureds or 5 business days after the insurer makes an offer
consistent with RSA 417:4, XV(a)(4), whichever is earlier.
(g)
If the insured or claimant chooses to keep the motor vehicle, the
settlement payment shall be the difference between the total loss value as
determined in (a) through (e) above and the salvage value for a motor vehicle
of like, kind, and
quality. Salvage value shall be
calculated based on the salvage value available in the northeast of the United States or upon the salvage
value available to the insurer from any salvage facility that is utilized by
the insurer in the normal course of the insurer's business. Any costs that the insurer would have
incurred for storage or transportation to any salvage facility shall be deducted
from the salvage value.
(h)
The methodology required by (a)(1) above shall be developed and
submitted according to the following:
(1) In order for a methodology to be acceptable,
the insurer, or vendor on behalf of the insurer, shall submit to the department
a description of its methodology or model accompanied by supporting
details. Supporting details shall
include a discussion of how the valuation process or model is designed and an
analytical or statistical validation of the assumptions, parameters, data
elements, and results of the process or model.
Any methodology that is not analytically or statistically valid shall be
rejected;
(2) The department shall publish a list annually,
at the beginning of the calendar year, of accepted valuation guides and
methodologies. Insurers shall be
required to use one of the department’s accepted methodologies;
(3) If there are any changes made to the process
or methodology provided to the department pursuant to (a)(1) above, the insurer
or vendor shall provide the department with details as to the changes being
made so that the department can determine whether the process or method shall
remain on the accepted list; and
(4) Information submitted to the department
pursuant to this section shall be:
a. Considered confidential and commercial
information under RSA 91-A:5, not subject to disclosure; and
b. Treated as confidential by the commissioner,
pursuant to RSA 400-A:25.
Source. #8900, eff 7-1-07, EXPIRED: 7-1-15
New. #10962, eff 10-26-15; ss by #13173, eff 4-26-21
Ins 1002.16 Willing and Able Contractors and Repairers; Other
Than Motor Vehicle.
(a) Every settlement
offer that is based upon an appraisal conducted on behalf of the insurer
relative to property and liability insurance
shall:
(1) Include a written statement that, if the
claimant or insured cannot find a contractor or repairer to do the repair or
replace the damage property for the price quoted, then the insured or claimant
may request that the insurer supply the insured or claimant with the name and
address of any known recognized, competent and conveniently located contractor
or repairer who is willing and able to repair or replace the damaged property
with other property of like kind and quality within a reasonable time for the price quoted in the appraisal or as otherwise provided for in the
insurance policy;
(2) If the insurer provides the insured or
claimant with the name of a contractor or repairer as set forth
in (a)(1) above, the insurer shall also provide a written
disclosure that any contractor or repairer may be used at the discretion of the
insured or claimant; and
(3) If the insurer is unable to provide the name
of a contractor or repairer upon request, then any fair and reasonable cost
incurred to repair or replace the damage as set forth in the appraisal, in excess of the insurer's appraisal price, shall be at the
expense of the insurer. If the insurer
has provided the insured or claimant with the name of a contractor or repairer
who is willing and able to repair or replace the damaged property with other
property of like kind and quality within a reasonable time for the price quoted
in the appraisal and the insured or claimant uses another contactor or
repairer, then any cost in excess of the insurer's
appraisal prices shall not be at the expense of the insurer.
(b) The insured or claimant shall be entitled to the
usual and customary guarantees as to materials and workmanship relative to the
property that is being repaired or replaced.
(c) In processing
any claim for damage to a home, dwelling, or other property, the insurer shall
not require as a condition to the payment of such claims that repairs be made
by a particular contractor or repairer.
(d) Any settlement
made based upon an agreement negotiated by an adjuster on behalf of the insurer
with a contractor or repairer shall include a provision for coverage of hidden
damage that is determined to be connected with the
claim in question.
(e) For all claims, insurers and their adjusters, whether hired under contract
or employed, shall not make any coercive, threatening, or intimidating
statements at any time, orally or in writing, to an insured or claimant for the
purpose of influencing the insured’s or claimant's choice of a particular
contractor or repairer.
(f) In addition to the above requirements, every settlement made or offered by the
insurer to repair or replace damaged jewelry, watches, precious, or
semi-precious stones, under applicable property insurance, shall comply with
the provisions of Ins 1002.18.
Source. #8900, eff 7-1-07; amd by #9495, eff
6-29-09; ss by #10962, eff 10-26-15
Ins 1002.17 Willing
and Able Repair Facilities; Motor Vehicle Insurance.
(a) Every settlement
offer that is based upon an appraisal conducted on behalf of the insurer
relative to property and liability insurance
shall:
(1) Represent the fair and reasonable price in
the area charged by repair shops or facilities providing similar services with
the usual and customary guarantees as to materials and workmanship;
(2) Include a written statement that the insurer
shall supply to the insured or claimant the name and address of a recognized,
competent, and conveniently located repair shop or facility who is willing and
able to repair or replace the damaged motor vehicle with another of like kind
and quality within a reasonable time for the price quoted in the appraisal; and
(3) Include in the written statement a disclosure
that any repair shop or facility may be used at the discretion of the insured
or claimant.
(b) The insured or claimant shall be entitled to the usual and customary guarantees as to
materials and workmanship relative to the motor vehicle that is being repaired
or replaced.
(c) If the insurer
is unable to provide the name of a repair shop or facility upon request, any
additional repair or replacement costs
incurred in excess of the insurer’s appraisal price
shall be at the expense of the insurer.
(d) In processing
any claim for any damage to a motor vehicle, the insurer shall not require as a
condition to the payment of such claims, that repairs be made in a particular
repair shop or facility.
(e) Insurers
specifying the use of after-market parts shall:
(1) Pursuant to RSA 407-D:4, not require the use
of after-market parts unless the parts are at least equal in like, kind, and
quality to the original part in terms of fit, quality, and performance;
(2) Not require the use of after-market parts
unless the insurer states or certifies
in writing that the part is of like, kind, and quality; and
(3) Consider the cost of any modifications,
re-repairs, or delays that might become necessary when making the repair.
(f) Any settlement
made based upon an agreement negotiated by an appraiser or an adjuster on
behalf of the insurer with a repair shop or facility shall include a provision
providing for coverage of hidden damage that is determined to be connected with the claim in question.
(g) If an
independent repair shop or facility and an insurer are unable to agree on a
price, and the insurer has complied with (a) through (f) above, then:
(1) The price shall be the price available from
any other recognized, competent, and conveniently located independent repair
shop or facility that is willing and able to repair the damaged motor vehicle
within a reasonable time; and
(2) The insurer shall furnish to the insured or
claimant a written statement
containing the following disclosure:
“Under New Hampshire law,
you are always entitled to use the repair shop or facility of your choice. Unfortunately, we have been unable to agree
on price with the facility you have chosen.
In this situation, New Hampshire law provides that our payment for
repair cost may be limited to the price available from a recognized, competent, and conveniently located
independent repair shop or facility that is willing and able to repair the
damaged motor vehicle within a reasonable time.
You may be responsible for the difference between our payment and the
price charged to you by the facility you have chosen. Upon your request, we will furnish a written
disclosure of the factual basis for our determination of the fair and
reasonable price. If you are our insured
and disagree with our determination
of the amount of loss, you are entitled to exercise the appraisal provision of
your policy."
(h) For all claims,
insurers and their appraisers and adjusters, whether hired under contract or
employed, shall not make any coercive, threatening, or intimidating statements
at any time, orally or in writing, to insureds or claimants for the purpose of
influencing the insureds’ or claimants’ choice of
repair shop or facility.
Source. #8900, eff 7-1-07,
EXPIRED: 7-1-15
New. #10962, eff 10-26-15;
ss by #13173, eff 4-26-21
Ins 1002.18 Additional Requirements,
Settlement of Jewelry Claims.
(a) In addition to any other requirements set
forth in this part, every settlement made or offered by the insurer to replace
or repair lost or damaged jewelry, watches, precious, or semi-precious stones,
under applicable property insurance, shall also:
(1) Be based
upon an appraisal which reflects values of such property of like kind and
quality found in the local market area; and
(2) Include a notice to the insured or claimant that
they may request an appraisal from an appraiser having no arrangement with the
insurer, and of their choosing, in order to receive
validation that the insurer's settlement offer reflects a fair market value and
that the resulting repaired or replaced property will be of like kind and
quality.
(b) If the insurer provides the insured or
claimant with the name of the seller or repairer as set forth pursuant to Ins 1002.16 (a)(1), the insurer shall also provide a written
disclosure as to the nature of any business arrangement between the insurer and
the seller or repairer.
Source. #9495, eff 6-29-09,
EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1002.19 Miscellaneous Provisions.
(a) Pursuant to RSA 412:8, III, an insurer shall not apply an
insured's collision deductible when the damage is:
(1) Caused by an uninsured motor vehicle;
(2) The operator of the
uninsured motor vehicle has been positively identified; and
(3) The operator of the uninsured motor vehicle
is solely at fault.
(b) Every insurer
shall exercise due diligence in determining whether the requirements in (a)
above have been met and shall make payment of the collision deductible as soon
as practicable and not later than 30 days from the
determination.
(c) Every insurer
shall exercise due diligence in the pursuit of subrogation on behalf of the insured. Upon receipt of the final
subrogation recovery, the insurer shall return the insured’s portion as soon as
practical but not later than 30 days from receipt of the final recovery.
Source. #8900, eff
7-1-07; renumbered by #9495 (from Ins 1002.18),
EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1002.20 Insurer Documentation. Every insurer shall maintain in its files, in
either written or electronic form, physical evidence of compliance with all of the provisions of this part and RSA 400-B.
Source. #8900, eff
7-1-07; renumbered by #9495 (from Ins 1002.19),
EXPIRED: 7-1-15
New. #10962, eff 10-26-15
Ins 1002.21 Penalty. Any
insurer or representative thereof who shall knowingly violate any provision of
this part shall be subject to the provisions of RSA 400-A:15, III.
Source. #8900, eff
7-1-07; renumbered by #9495 (from Ins 1002.20),
EXPIRED: 7-1-15
New. #10962, eff 10-26-15
APPENDIX
|
RULE |
|
|
|
|
|
Ins 1001.01 |
RSA 400-A:15, |
|
Ins 1001.02 |
RSA 400-A:15, I; RSA 417:3; RSA 417:4, XV |
|
Ins 1001.03 |
RSA 400-A:15, |
|
Ins 1001.04 |
RSA 400-A:15, |
|
Ins 1001.05 |
RSA 400-A:15, I; RSA 417:3 |
|
Ins 1001.06 |
RSA 400-A:15, |
|
Ins 1001.07 |
RSA 400-A:15, |
|
Ins 1001.08 |
RSA 400-A:15, |
|
Ins 1001.09 |
RSA 400-A:15, |
|
Ins 1001.10 |
RSA 400-A:15, |
|
Ins 1001.11 |
RSA 400-A:15, |
|
|
|
|
Ins 1002.01 |
RSA 400-A:15, I; RSA 412:3, XI; RSA 417:4, XV |
|
Ins 1002.02 |
RSA 400-A:15, I. |
|
Ins 1002.03 |
RSA 400-A:15, |
|
Ins 1002.04 |
RSA 400-A:15, |
|
Ins 1002.05 |
RSA 400-A:15, |
|
Ins 1002.06 |
RSA 400-A:15, |
|
Ins 1002.07 |
RSA 400-A:15, |
|
Ins 1002.08 |
RSA 400-A:15, I..; 417:4, XV. (a)(10) |
|
Ins 1002.09 |
RSA 400-A:15, |
|
Ins 1002.09 (d) |
RSA 400-A:15, |
|
Ins 1002.10 |
RSA 400-A:15, |
|
Ins 1002.11 |
RSA 400-A:15, |
|
Ins 1002.12 |
RSA 400-A:15, |
|
Ins 1002.13 |
RSA 400-A:15, |
|
Ins 1002.14 |
RSA 400-A:15, |
|
Ins 1002.15 |
RSA 400-A:15, I; RSA 417:4, XV and XX |
|
Ins 1002.16 |
RSA 400-A:15, |
|
Ins 1002.16 (f) |
RSA 400-A:15, |
|
Ins 1002.17 |
RSA 400-A:15, I; RSA 407-D:3; RSA 407:3-a; RSA
407-D:4; RSA 417:4, XX |
|
Ins 1002.18 |
RSA 400-A:15, |
|
Ins 1002.19 |
RSA 400-A:15, |
|
Ins 1002.20 |
RSA 400-A:15, |
|
Ins 1002.21 |
RSA 400-A:15, |