N.J. Admin. Code § 11:16-6.6
Current through Register Vol. 56, No. 21, November 4, 2024
Section 11:16-6.6 - Fraud prevention and detection plan(a) The plan shall provide for underwriting inquiry to verify that the insured satisfies the insurer's acceptance criteria and that the policy is properly rated within 60 days of receipt of the application. These underwriting inquiries shall verify the insured's residency provided by the insured on his or her application for insurance. The plan may provide that these inquiries are generally done "in-house" by telephone and by using information from the New Jersey Motor Vehicle Commission (or similar agencies in other states) and prior insurers.(b) The following concern referral of applications and claims. 1. The plan shall provide that an application or claim shall be referred to the Bureau and OIFP, for further investigation or other appropriate action. The referral shall be made either using electronic referral forms that may be established by the Commissioner and the Insurance Fraud Prosecutor, or using the applicable hard-copy Referral Form OIFP/BFD-1 for Claim Fraud, OIFP/BFD-2 for Application Fraud, OIFP/BFD-3 for Health Claim Fraud, and OIFP/BFD-4 for Health Application Fraud indicating "REFERRAL." The hard-copy referral forms are reproduced in the subchapter Appendix, incorporated herein by reference. The plan shall provide that the referral shall include all information required by the electronic referral form or the hard-copy referral form, when the investigation complies with the requirements set forth in 11:16-6.7.2. The plan shall provide that all applications and claims, which meet the standard for referral set forth in N.J.A.C. 11:16-6.7, shall be referred to OIFP by the SIU as soon as practicable, but in no case later than 30 days from when the investigation is complete.3. The plan shall provide criteria and levels of economic impact for the referral of insurance claims and application fraud in accordance with the requirements of N.J.A.C. 11:16-6.7.(c) The plan shall provide that after completion of an SIU investigation, or after identification by an SIU of a pattern of applications or claims, the insurer shall provide notice to the Bureau and the OIFP using OIFP/BFD Form 1, OIFP/BFD Form 2, OIFP/BFD Form 3, or OIFP/BFD Form 4, indicating "NOTIFICATION," unless these forms are superseded by an electronic reporting form established by the Commissioner and the Insurance Fraud Prosecutor, of instances in which a violation of 17:33A-4 is suspected on the basis of fraud factors or indicators, but where sufficient evidence to support a case referral pursuant to 11:16-6.7 has not been developed.(d) The plan shall provide that all referrals of application and claims fraud and notifications of suspected application or claims fraud by the insurer to OIFP shall be made by personnel in the insurer's SIU or other personnel designated in the plan so long as records are kept of all referrals and notifications and the appropriate form is used.(e) Where an insurer contracts any of its SIU functions to an outside vendor or third party administrator in accordance with 11:16-6.4(e), the plan shall provide the name and address of the outside vendor or third party administrator used by the insurer to conduct investigations or perform SIU functions together with a copy of the contract between the insurer and the outside vendor or third party administrator.(f) The plan may include such other items as the insurer may wish to provide.N.J. Admin. Code § 11:16-6.6
Amended by R.2001 d.76, effective 3/5/2001.
See: 32 N.J.R. 4197(a), 33 N.J.R. 804(a).
Rewrote (b)1 and (c).
Amended by R.2006 d.308, effective 9/5/2006.
See: 38 N.J.R. 1276(a), 38 N.J.R. 3592(a).
Rewrote (b)1 and (c).
Amended by R.2008 d.380, effective 12/15/2008 (operative January 1, 2009).
See: 40 N.J.R. 3572(a), 40 N.J.R. 6970(b).
In (a), substituted "satisfies the insurer's acceptance criteria" for "is an eligible person" and inserted "that" preceding "the policy", and substituted "New Jersey Motor Vehicle Commission" for "New Jersey Division of Motor Vehicle Services".
Amended by R.2014 d.035, effective 2/18/2014.
See: 45 N.J.R. 1989(a), 46 N.J.R. 358(a).
Rewrote (b)1 and (c).