N.J. Admin. Code § 11:25-1.1

Current through Register Vol. 57, No. 1, January 6, 2025

Section 11:25-1.1 - Purpose and scope

(a) The purpose of this subchapter is to establish procedures for the Insurance Claims Ombudsman to exercise his or her statutory authority to:

1. Investigate consumer complaints involving policies of insurance, including the payment of claims;

2. Monitor the implementation of N.J.S.A. 17:23A-1 et seq. (policyholder's personal information disclosure practices of regulated insurers);

3. Monitor the implementation of N.J.S.A. 17:29B-1 et seq. and 17B:30-1 et seq. (consumer complaints regarding unfair methods of competition; unfair, deceptive and discriminatory acts or practices by insurers);

4. Monitor the implementation of N.J.S.A. 17:35C-1 et seq. (Medicare supplement health insurance policies; regulation of contract provisions and required disclosure to consumers);

5. Investigate alleged violations of N.J.S.A. 17:35C-11 (use of false, misleading, or fraudulent statements and advertising to sell Medicare supplement insurance to consumers);

6. Respond to consumer inquiries, including, but not limited to, those regarding policy terms and availability of coverage;

7. Ensure that accurate and understandable buyers' guides and rate comparisons are published and disseminated to consumers where required by law, except those with respect to health insurance coverages provided pursuant to N.J.S.A. 17B:27A-2 et seq. and 17B:27A-17 et seq.;

8. Review the conduct of arbitrators appointed in accordance with the terms of a policy of insurance to arbitrate disputes, except those arbitration proceedings arising out of policies issued pursuant to N.J.S.A. 39:6A-1 et seq. or already subject to the provisions of N.J.A.C. 11:22-1;

9. Investigate such other improper patterns or practices as are deemed necessary and appropriate to the Office of Insurance Claims Ombudsman; and

10. Review disputes that are appealed by consumers after an internal appeals procedure (N.J.A.C. 11:25-2) is conducted by life, property and casualty insurers.

(b) This subchapter shall apply to all claims filed under a policy of insurance issued in accordance with N.J.S.A. 17:17-1, 39:6A-1 et seq., or any policy of life or health insurance issued in accordance with Title 17 or Title 17B of the New Jersey Statutes, except any dispute which may be or has been filed or adjudicated pursuant to N.J.S.A. 39:6A-5.1 and 39:6A-5.2 (PIP Alternate Dispute Resolution) shall not be subject to the Ombudsman's review.

N.J. Admin. Code § 11:25-1.1