3 Colo. Code Regs. § 702-6-5-1-4

Current through Register Vol. 47, No. 7, April 10, 2024

Section 3 CCR 702-6-5-1-4 - Definitions

A. "Authorized agency" shall have the same meaning as provided in § 10-4-1002(1), C.R.S.

B. "Concealment" means the knowing concealment of a material fact by impeding the discovery of the material fact, by misrepresentation or by willful omission.

C. "Fraudulent insurance act" includes an act done by a person, with intent to defraud, in presenting, causing to be presented, or prepares with the knowledge or belief that it will be presented, to or by an insurer, a purported insurer, a producer, or any representative thereof; a written statement as part, or in support of, an application for the issuance or the rating of an insurance policy or a claim for payment or other benefit pursuant to an insurance policy that he or she knows to contain false information concerning any fact material thereto; any act done by a person, knowingly and with intent to defraud or mislead conceals information concerning any fact or circumstance material thereto; or any act described as a criminal offense in Titles 8, 10, 12, and 18, C.R.S., regarding the provision or acquisition of any policy of insurance, the misappropriation of any payment of premium or benefit, the presentation of payment of claim or insurance benefit, or any other matter.

D. "Insurer" means every person engaged as principal, indemnitor, surety, or contractor in the business of making contracts of insurance and every insurer and any person licensed or regulated under Title 10, C.R.S. and Pinnacol Assurance.

E. "Intentionally" or "with intent". A person acts intentionally or with intent with the person's conscious objective is to cause the specific result proscribed by a statute defining an offense, or a rule or regulation requiring or prohibiting a particular action. It is immaterial to the issue of intent whether or not the result actually occurred.

F. "Material fact". A fact is material if a reasonable person under the circumstances would attach importance to it in making a decision or determining a course of action, including but not limited to the issuance of a policy, the payment or acceptance of premiums, the submission of a claim, the scope or direction of an investigation, whether a claim should be paid or not, or the amount to be paid on a claim or benefit to any party.

G. "Medical record" means the written or graphic documentation, sound recording, or computer record of services pertaining to medical and health care which are performed at the direction of a physician or other licensed health care provider on behalf of a patient by physicians, dentists, nurses, technicians, emergency medical technicians, pre-hospital providers or other healthcare personnel. Medical record includes such diagnostic documentations as x-rays, electrocardiograms, electroencephalograms, and other test results.

H. "Misrepresentation" means any oral or written communication or conduct, or combination of communication and conduct that is untrue and is intended to create a misleading impression in the mind of another.

I. "NAIC Online Fraud Reporting System" means the online, consumer accessible reporting system hosted by the National Association of Insurance Commissioners and located at https://eapps.naic.org/ofrs/ofrsHome.jsp

J. "Notice" or "notify" means the notification, in writing to an Authorized agency or a Secondary Agency by any person or insurer.

K. "Person" means every natural person, firm, partnership, association, or corporation, or other business entity or trust, except insurers.

L. "Policy" means an individual or group policy, group certificate, contract or arrangement of insurance or reinsurance affecting the rights of a resident of this state or bearing a reasonable relation to this state, regardless of whether delivered or issued for delivery in this state.

M. "Relevant" means any information having a tendency to make the existence of any fact that is of consequence to the investigation or determination or the issue more probable or less probable than it would be without the information or evidence.

N. "Secondary Agency" shall have the same meaning as provided in § 10-4-1002(6), C.R.S. Secondary Agencies shall include, but not be limited to, the National Insurance Crime Bureau (NICB), the National Association of Insurance Commissioners (NAIC) and the National Health Care Anti-Fraud Association (NHCAA).

3 CCR 702-6-5-1-4

38 CR 18, September 25, 2015, effective 10/15/2015

39 CR 01, January 10, 2016, effective 2/1/2016

40 CR 24, December 25, 2017, effective 1/14/2018

41 CR 08, April 25, 2018, effective 6/1/2018