N.H. Admin. Code § Ins 4601.05

Current through Register No. 50, December 12, 2024

Section 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.

N.H. Admin. Code § Ins 4601.05

#10024, eff 11-14-11

Amended by Volume XLI Number 1, Filed January 7, 2021, Proposed by #13148, Effective 12/28/2020, Expires 12/28/2030