CHAPTER Ins 4600 ANTIFRAUD PLAN STANDARDS
Authority: RSA 400-A:15, I; RSA 408-D:17, I&V; RSA
417:31; RSA 541-A:21, VI(a)(2)
PART Ins 4601 ANTIFRAUD PLANS
Ins 4601.01 Purpose. The purpose of this chapter is to establish
standards for the insurance fraud investigation unit, insurance company special
investigative unit (SIU), and any other interested parties regarding the
preparation of an antifraud plan that meets the mandated requirements for
developing an antifraud plan pursuant to RSA 417:30.
Source. #10024, eff
11-14-11; ss by #13148, eff 12-28-20
Ins 4601.02 Applicability and Scope. This chapter shall be applicable to every
insurance company licensed to write direct business in this state, except for
insurance companies writing only credit, home warranty, travel, or title
insurance.
Source. #10024, eff 11-14-11; ss by #13148, eff 12-28-20
Ins 4601.03 Definitions.
(a)
"Commissioner" means the insurance commissioner.
(b)
"Department" means the New Hampshire Insurance Department.
(c) "National
Association of Insurance Commissioners (NAIC)" means the organization
comprised of elected or appointed state government officials of the 50 states,
the District of Columbia,
and the U.S. territories whose departments regulate the business of insurance.
(d) "National
Health Care Antifraud Association (NHCAA)" means the organization founded
in 1985 by private health insurers and federal and state governments whose
activities focus exclusively on fighting health care fraud.
(e) "National Insurance
Crime Bureau (NCIB)" means the not-for-profit organization created by the
insurance industry to address insurance-related crime.
(f) "Online
Fraud Reporting System (OFRS)" means the online fraud reporting system
developed by the NAIC for regulators, consumers,
and insurance industry to report insurance fraud.
(g) "Special
Investigations Unit (SIU)" means the non-law enforcement units of an
insurer or insurer affiliated entity whose sole mission is to detect, deter,
defeat, and report insurance fraud. An
SIU includes any of the following:
(1) An internal unit of the insurance company;
(2) An external unit of more than one insurance
company that is part of the same insurance holding company system;
or
(3) An independent third-party unit under
contract with an insurer or insurers.
Source. #10024, eff 11-14-11; ss by #13148, eff 12-28-20
Ins 4601.04 Antifraud Plans Submitted
Upon Request.
(a) An insurer, if
requested by the department, subject to RSA 408-D:14 and RSA 417:30, shall submit
to the commissioner a detailed description of the company's antifraud
plan.
(b) Any antifraud
plans so submitted shall be subject to review by the commissioner.
Source. #10024, eff 11-14-11; ss by #13148, eff 12-28-20
Ins 4601.05 Antifraud Plan Requirements.
(a) The antifraud
plan shall be an acknowledgement by the insurer and its SIU that they have
established criteria that shall be used to detect suspicious or fraudulent
insurance activity relating to the different types of insurance offered by that
insurer.
(b) One SIU
antifraud plan may cover several insurer affiliated entities if one SIU has the
fraud investigation mission for all entities.
(c) The following
information shall be included in the antifraud plan to satisfy the requirements
of this chapter, RSA 408-D:14, and RSA 417:30:
(1) General information requirements including:
a. An acknowledgment that the SIU has
established criteria that shall be used for the investigation of acts of
suspected insurance fraud relating to the different types of insurance offered
by that insurer;
b. An acknowledgment that the insurer or SIU
shall record the date that suspected fraudulent activity is detected and shall
record the date that reports of such suspected insurance fraud were sent
directly to the department, with a specific time frame which is consistent with
RSA 417:28;
c. A provision stating whether the SIU is an
internal unit or an external or third-party unit;
d. If the SIU is an internal unit, provide a
description of whether the unit is part of the insurer's claims or underwriting
departments, or whether it is separate from such departments;
e. A written description or chart outlining the
organizational arrangement of the insurer's antifraud positions responsible for
the investigation and reporting of possible fraudulent insurance acts,
including:
1. If the SIU is an internal unit, the insurer
shall provide general contact information for the company's SIU;
2. If the SIU is an external unit, the insurer
shall provide:
(i) The name of the company or companies used;
(ii) Contact information for the company;
(iii) A company
organizational chart; and
(iv) The person or position at the insurer
responsible for maintaining contact with the external SIU company; and
3. If an external SIU is employed for purposes
of surveillance, the insurer shall include a description of the policies and
procedures implemented;
f. A provision where the insurer provides the
NAIC individual and group code numbers;
g. A statement as to whether the insurer has
implemented a fraud awareness or outreach program. If the insurer has an awareness or outreach
program, a brief description of the program shall be included; and
h. If the SIU is a third-party, a description of
the insurer's policies and procedures for ensuring that the third-party unit
fulfills its contractual obligations to the insurer and a copy of the contract
with the third party vendor;
(2) Prevention, detection, and investigation of
fraud information, including:
a. A description of the insurer's corporate
policies for preventing fraudulent insurance acts by its policy holders;
b. A description of the insurer's established
fraud detection procedures, such as technology and other detection procedures;
c. A description of the internal referral
criteria used in reporting suspicious claims of insurance fraud for
investigation by the SIU;
d. A description of the SIU investigation
program, such as by business line, external form claims adjustment, vendor
management standard, operating procedures; and
e. A description of the insurer's policies and
procedures for referring suspicious or fraudulent activity from the claims or
underwriting departments to the SIU;
(3) Reporting of fraud information, including:
a. A description of the insurer's reporting
procedures for the mandatory reporting of possible fraudulent insurance acts to
the commissioner pursuant to RSA 408-D:14, RSA 417:28, and RSA 417:30;
b. A description of the insurer's criteria or
threshold for reporting fraud to the commissioner; and
c. A description of the insurer's means of
submission of reports of suspected fraud to the commissioner, such as through
the NAIC, OFRS, NICB, NHCAA, electronic state system, or other means;
(4) Education and training information,
including, if applicable, a description of the insurer's plan for antifraud
education and training initiatives of any personnel involved in antifraud
related efforts. Such description shall
include:
a. The internal positions
the insurer offers regular education and training, such as underwriters,
adjusters, claims representatives, appointment agents, and attorneys, etc.;
b. If the training will be internal or external;
c. Number of hours expected per year; and
d. If training includes ethics, false claims, or
other legal-related issues;
(5) Internal fraud detection and prevention
information, including:
a. A description of the insurer's internal fraud
detection policy for employees, consultants, or others, such as underwriters,
claims representatives, appointed agents, etc.; and
b. A description of the insurer's internal fraud
reporting system.
Source. #10024, eff
11-14-11; ss by #13148, eff 12-28-20
Ins 4601.06 Regulatory Compliance. Pursuant to RSA 417:30, the department shall
review insurer antifraud plans, as needed, in order to
determine compliance with appropriate state laws. Further, the department shall, in accordance
with RSA 417:30, IV, take appropriate administrative action against an insurer
that fails to comply with the mandated requirements or state laws.
Source. #10024, eff 11-14-11; ss by #13148, eff
12-28-20 (formerly Ins 4601.07)
Ins 4601.07 Confidentiality of Antifraud
Plans. Any requested submission of
required information shall not constitute a waiver of an insurer's privilege,
trade secret, confidentiality, or any proprietary interest in its antifraud
plan or its antifraud related policies and procedures. The commissioner shall maintain the antifraud
plan as confidential. Submitted plans
shall not be subject to RSA 91-A, if submitted properly under the state
statutes or rules which would afford protection of these materials under RSA
408-D:14 and RSA 417:30, II.
Source. #10024, eff 11-14-11; ss by #13148, eff
12-28-20 (formerly Ins 4601.08)
Ins 4601.08 Waiver of Rules.
(a) The
commissioner, upon the commissioner’s own initiative or upon request by an
insurer, shall waive any requirement of this chapter if such waiver does not
contradict the objective or intent of the rule and:
(1) Applying the rule provision would cause
confusion or would be misleading to consumers;
(2) The rule provision is in whole or in part
inapplicable to the given circumstances;
(3) There are specific circumstances unique to
the situation such that strict compliance with the rule would be onerous
without promoting the objective or intent of the rule provision; or
(4) Any other similar extenuating circumstances
exist such that application of an alternative standard or procedure better
promotes the objective or intent of the rule provision.
(b) No requirement
prescribed by statute shall be waived unless expressly authorized by law.
(c) Any person or
entity seeking a waiver shall make a request in writing.
(d) A request for a
waiver shall specify the basis for the waiver and proposed alternative, if any.
Source. #10024, eff 11-14-11; ss by #13148, eff 12-28-20
Rule
|
Statute
|
|
|
Ins
4601.01 |
RSA
400-A:15, I.; RSA 408-D:14; RSA 408-D:17; RSA 417:23; RSA 417:31 |
Ins
4601.02 |
RSA
400-A:15, I; RSA 408-D:17; RSA 417:30; RSA 417:31 |
Ins
4601.03 |
RSA
400-A:15, I; RSA 417:31; RSA 541-A:21, VI(a)(2) |
Ins
4601.04 |
RSA
400-A:15, I; RSA 408-D:14;
RSA 417:30 |
Ins
4601.05 |
RSA
400-A:15, I; RSA 408-D:14; RSA 408-D:17; RSA 417:28; RSA 417:30; RSA 417:31 |
Ins
4601.06 |
RSA
400-A:15, I; RSA 417:30 |
Ins
4601.07 |
RSA
400-A:15, I; RSA 400-A:16; RSA 400-A:37; RSA 408-D:14; RSA 408-D:17; RSA 417:30; RSA 417:31 |
Ins
4601.08 |
RSA
400-A:15, I; RSA 541-A:22, IV |