Md. Code Regs. 31.15.08.03

Current through Register Vol. 51, No. 21, October 18, 2024

Section 31.15.08.03 - Unfair Claim Settlement Practices

A. A prohibited unfair claim settlement practice occurs if an insurer commits any of the following acts:

(1) Misrepresents or provides incomplete or misleading disclosures of pertinent facts or policy provisions relating to the claim at issue;

(2) Conceals benefits, coverages, or other provisions of a policy when those benefits, coverages, or other provisions are pertinent to a claim;

(3) Attempts to settle a claim on the basis of an application which has been altered without notice to, or the knowledge or consent of, the insured;

(4) Refuses to satisfy a claim for an arbitrary or capricious reason based on all available information;

(5) Fails to include, in any claim paid to an insured or beneficiary, a statement setting forth the coverage under which the payment is made;

(6) Fails to settle a claim promptly whenever liability is reasonably clear under one portion of a policy in order to influence settlements under other portions of the policy; or

(7) Fails to promptly provide a reasonable explanation of the basis for denial of a claim when requested to do so.

B. A prohibited unfair claim settlement practice occurs if an insurer commits any of the following acts with such frequency as to indicate a general business practice:

(1) Misrepresents or provides incomplete or misleading disclosure of pertinent facts or policy provisions relating to the coverages at issue;

(2) Fails to include, in claims paid to insureds or beneficiaries, statements setting forth the coverage under which the payments are made;

(3) Fails to promptly provide reasonable explanations of the basis for denial of claims or the offer of compromise settlements;

(4) Fails to adopt and implement reasonable standards for the prompt investigation of claims arising under policies;

(5) Refuses to pay claims without conducting reasonable investigations based on all available information;

(6) Fails to make good faith attempts to settle claims promptly, fairly, and equitably once liability has become reasonably clear;

(7) Compels claimants to institute litigation to recover amounts due them under policies by offering substantially less than the amounts ultimately recovered in actions brought by the claimants;

(8) Attempts to settle claims for less than the amount to which a reasonable person would expect to be entitled after studying written or printed advertising material accompanying, or made a part of, applications or solicitations for insurance;

(9) Attempts to settle claims on the basis of applications which have been altered without notice to, or the knowledge or consent of, insureds;

(10) Fails to settle claims promptly whenever liability is reasonably clear under one portion of a policy in order to influence settlements under other portions of the policy;

(11) Delays investigations or payments of claims by requiring claimants, or claimants' licensed health care providers, to submit formal claims reports if all necessary information has been provided to the insurer in preliminary claims reports;

(12) Fails, within 30 days after receipt of a claim that contains all necessary information and documentation, to:

(a) Make payment of the claim,

(b) Notify the claimant that reimbursement for the claim, or a portion of the claim, is refused, providing specific reasons for the refusal, or

(c) Inform the claimant of the reason it was not reasonably practicable to process the claim within that period, stating what specific additional information is needed before a decision on the claim can be made;

(13) Fails, upon receipt of inquiries from state insurance departments regarding claims, to furnish the departments with adequate responses to the inquiries within 10 working days or within the time period specified by the Maryland Insurance Administration in correspondence to the insurer, whichever is greater;

(14) Induces or requires claimants to surrender policies as a condition of paying claims if the policies would normally continue in force beyond the date of payment of the claim; or

(15) Fails to provide claimants, within 10 working days after receiving notification of claims, with any necessary claim forms, instructions, and reasonable assistance in order that claimants can comply with the policy conditions and the insurer's reasonable requirements for filing claims.

C. The provision of any necessary claim forms and reasonable assistance in order that claimants can comply with the policy provisions and the insurer's reasonable requirements for filing claims shall satisfy the requirement that insurers acknowledge receipt of notification of claims, or pay claims, within 10 working days.

Md. Code Regs. 31.15.08.03

Regulation .03B amended effective September 13, 1993 (20:18 Md. R. 1429)
Regulation .03B amended effective January 26, 2009 (36:2 Md. R. 103)