N.J. Admin. Code § 11:4-17.6

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:4-17.6 - Complaint record to be maintained

(a)N.J.S.A. 17B:30-13.2 requires the maintenance of complaint records. The following requirements prescribed the minimum information to be maintained in order to comply with the statute.

1. The minimum information required to be contained in a person's complaint record is set forth in (b) below. Refinements and additions to the information specified may, of course, be maintained in such complaint record.

2. Subsection (b) below is the suggested format for the complaint record required to be maintained. Refinements, deviations from or additions to this suggested format are permitted so long as the minimum information contemplated by such format can be obtained for Insurance Department review within a reasonable time following a request therefor by an authorized representative of the Department.

3. Subsection (c) below contains an explanation of the various headings, codes, and other notations contained in (b) below. The codes are used in order to simplify both the identification of the action underlying the complaint and the keeping of the records.

4. The complaint record shall be kept on a calendar year basis and the number of complaints by line of insurance, function, reason, disposition and state of origin shall be compiled at least annually.

5. "Complaint" shall mean a written communication primarily expressing a grievance.

(b) Complaint record format:

COMPLAINT RECORD FORMAT
Column	Column		Column	Column
A	B		C	D
Company	Function	Reason	Line	Company
Identification	Code	Code	Type	Disposition
No. (Agent's	after
Number)	complaint
Complaint
receipt

COMPLAINT RECORD FORMAT
Column	Column	Column	Column
E	F	G	H
Date	Date	Insurance	State
Received	Closed	Dept.	of Origin
Complaint

(c) Explanation of complaint record code for Complaint Record Format in (b) above follows:

Column A: Company Identification Number. As noted, this refers to the identification number of the complaint and shall also include the license number or other means of identifying any licensee of the Insurance Department that may have been involved in the complaint.

Column B: Function Code. Complaints are to be classified by function(s) of the company involved. Separate classifications are to be maintained for underwriting, marketing and sales, claims, policy holder service and miscellaneous.

Column B: Reason Code: Complaints are also to be classified by the nature of the complaint. The following is the classification required for each function specified above.

1. Underwriting:

a Company underwriting;

b Individual's application underwriting (this refers to any complaint where misrepresentations or declarations in an application for insurance resulted in company action involved in the complaint);

c Cancellation;

d Recision;

e Nonrenewal;

f Premiums and rating;

g Delays;

h Refusal to insure;

i Miscellaneous (not covered by above).

2. Marketing and sales:

a General advertising;

b Direct response advertising;

c Agent handling;

d Replacement;

e Dividend illustration;

f Delays;

g Alleged misleading statement or misrepresentation;

h Miscellaneous (not covered by above).

3. Claims:

a Claims procedure;

b Delays;

c Unsatisfactory settlements;

d Natural disaster adjusting (hurricane or flood situations or other situations which produce a large number of claims);

e Unsatisfactory settlement offers;

f Denial of claim;

g Miscellaneous (not covered by above).

4. Policyholder service:

a Failure to respond;

b Delays;

c Miscellaneous (not covered by above).

5. Miscellaneous:

Column C: Line Type. Complaints are to be classified according to the line of insurance involved. To complete this column, insert (9) which indicates individual health.

Column D: Company Disposition After Receipt. The complaint record shall note the disposition of the complaint.

The following examples illustrate the type of information called for, but are not intended to be required language or to exhaust the possibilities:

1. Corrective action was taken;

2. No action was deemed necessary;

3. Satisfactory explanation was given to the complainant.

The complainant record need not note the specific action taken with respect to the complaint, so long as the action was appropriate to the circumstances. If the company wishes it may use a code for entries in this column.

Column E: Date Received. This refers to the date the complaint was received.

Column F: Date Closed. This refers to the date on which the complaint was disposed of whether by one action or a series of actions as may be present in connection with some complaints.

Column G: Insurance Department Complaint. Complaints are to be classified so as to indicate if the origin of the complaint was from an Insurance Department.

Column H: State of Origin. The complaint record should note the state from which the complaint originated. Ordinarily this will be the state of residence of the complainant.

N.J. Admin. Code § 11:4-17.6

Amended by R.1996 d.4, effective 1/2/1996.
See: 27 New Jersey Register 3557(a), 28 New Jersey Register 165(a).