N.Y. Comp. Codes R. & Regs. tit. 11 § 216.5

Current through Register Vol. 46, No. 18, May 1, 2024

Section 216.5 - Standards for prompt investigation of claims

(a)

(1) Every insurer shall commence an investigation of any claim filed by a claimant, or by a claimant's authorized representative, within 15 business days of receiving notice of claim. An insurer shall furnish to every claimant, or claimant's authorized representative, a notification of all items, statements and forms, if any, which the insurer reasonably believes will be required of the claimant, within 15 business days of receiving notice of the claim. A claim filed with an agent of an insurer shall be deemed to have been filed with the insurer unless, consistent with law or contract, such agent notifies the person filing the claim that the agent is not authorized to receive notices of claim.

(2)

(i) Notwithstanding paragraph (1) of this subdivision, the provisions of this paragraph shall apply to any claim filed on or after November 29, 2012 for loss, damage, or liability for loss, damage, or injury, occurring from October 26, 2012 through November 15, 2012 in the counties of Bronx, Kings, Nassau, New York, Orange, Queens, Richmond, Rockland, Suffolk or Westchester, including their adjacent waters, with respect to:

(a) loss of or damage to real property;

(b) loss of or damage to personal property; or

(c) other liabilities for loss of, damage to, or injury to persons or property.

(ii) Every insurer shall commence an investigation of any claim filed by a claimant, or by a claimant's authorized representative, within six business days of receiving notice of claim. If the insurer wishes its investigation to include an inspection of the damaged or destroyed property, the inspection, whether performed by the insurer, an independent adjuster, or other representative of the insurer, must occur within the time frames specified in this paragraph.

(iii) An insurer shall furnish to every claimant, or claimant's authorized representative, a written notification detailing all items, statements and forms, if any, that the insurer reasonably believes will be required of the claimant, within six business days of receiving notice of the claim.

(iv) A claim filed with an agent of an insurer shall be deemed to have been filed with the insurer unless, consistent with law or contract, the agent notifies the person filing the claim that the agent is not authorized to receive notices of claim.

(v) Where necessary to protect health or safety, a claimant may commence immediate repairs to heating systems, hot water systems, and necessary electrical connections, as well as exterior windows, exterior doors, and, for minor permanent repairs, exterior walls, in order to enable property to retain heat, and any policy requirement that the policyholder exhibit the remains of the property may be satisfied by the policyholder submitting proof of loss documentation of the damaged or destroyed property, including photographs or video recordings; material samples, if applicable; and inventories, as well as receipts for any repairs to or replacement of property. This subparagraph does not apply to claims under flood policies issued under the national flood insurance program.

(b) Where there is a reasonable basis, supported by specific information available for review by Department of Financial Services examiners, that the claimant has fraudulently caused or contributed to the loss, the insurer is relieved from the requirements of this Part. The provisions of this Part are suspended for the period required to investigate the alleged fraudulent aspects of the claim. The insurer must submit the report required by Part 86 (Criminal Investigations Unit) of this Title when an insurer determines that a loss is suspect.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 216.5