N.J. Admin. Code § 11:25-1.3
Current through Register Vol. 57, No. 1, January 6, 2025
Section 11:25-1.3 - General provisions; disputed claims(a) Upon the request of a consumer, the Ombudsman may conduct a review of any disputed insurance claim settlement where there is reasonable cause to believe that an insurer has failed or refused to settle a claim in accordance with the provisions of the policy or has engaged in any practice that may constitute a violation of N.J.S.A. 17:23A-1 et seq., 17:29B-1 et seq., 17:35C-1 et seq., 17B:30-1 et seq., or 17:35C-11; or(b) Consumers seeking review in accordance with (a) above shall file a complaint with the Ombudsman in any form, which indicates that the complainant is seeking review of a disputed claim. All complaints shall be sent to: New Jersey Department of Banking and Insurance
Consumer Assistance
20 West State Street
PO Box 329
Trenton, NJ 08625-0329
Telephone: (609) 292-7272
Telefax: (609) 292-2431 or (609) 777-0508
Automated Hotline: 1-800-446-7467
E-mail: ombudsman@dobi.nj.gov
Electronic complaint submissions: http://www.state.nj.us/dobi/consumer.htm
1. All complaints received by the Ombudsman shall be entered into the data tracking system of the Consumer Assistance Unit in the Office of Consumer Protection Services. The Ombudsman shall retain complaints for further action, or refer them to the Consumer Assistance Unit in the Office of Consumer Protection Services for disposition. The Consumer Assistance Unit in the Office of Consumer Protection Services may likewise refer matters to the Ombudsman. 2. If the Ombudsman needs further information on any complaint, the office shall notify the complainant of the additional information needed before any further action may be taken.3. A copy of the filed complaint shall be sent promptly to the respondent together with a transmittal letter that advises the respondent that an answer to the complaint must be filed no more than 15 business days after the date of receipt of the transmittal letter.4. The respondent may raise a general denial to the complainant's allegations and may also raise such other legal, contractual or equitable defenses, which explain or justify the actions of the respondent.5. Thereafter, the complainant shall be advised of the respondent's contentions and given an opportunity to rebut within 15 business days of receipt of the notice.6. When deemed appropriate, the Ombudsman may extend all time limits mentioned in this subsection. (c) At the discretion of the Ombudsman, an investigation and hearing may be conducted in person and under oath. 1. In the conduct of an investigation, the Ombudsman may, in his or her sole discretion: i. Investigate whether the insurer's actions, determinations and proceedings with respect to the claim were in accordance with the law and the policy;ii. Make any necessary and appropriate inquiries of the insurer or any other interested person to obtain such information as the Ombudsman deems necessary to the investigation;iii. Hold a hearing on the disputed claim;iv. Inspect any books and records that relate to the claim; andv. Issue subpoenas to compel the attendance of any person at a specific time and place, as well as require the production of any documents, books, records, papers, objects and other evidence deemed necessary and relevant to the claim under investigation.2. The Ombudsman may elect not to investigate a complaint if it is determined that: i. The complaint is trivial, frivolous, vexatious or not made in good faith;ii. The complaint has been too long delayed to justify further investigation;iii. The resources available, considering the established priorities, are insufficient for an adequate investigation;iv. The matter complained of is not within the investigatory authority of the Ombudsman; orv. The subject is already under investigation by the Department or the Bureau of Fraud Deterrence.N.J. Admin. Code § 11:25-1.3
Amended by 46 N.J.R. 2279(b), effective 11/17/2014Amended by 53 N.J.R. 2227(a), effective 12/20/2021