Or. Admin. Code § 836-080-0235

Current through Register Vol. 63, No. 11, November 1, 2024

Section 836-080-0235 - Standards for Prompt and Fair Settlements - Generally

(1) An insurer shall, not later than the 30th day after its receipt of properly executed proofs of loss from a first party claimant, advise the claimant of the acceptance or denial of the claim. An insurer shall not deny a claim on the grounds of a specific policy provision, condition or exclusion unless the denial includes reference to the provision, condition or exclusion. A claim denial must be in writing, with either a copy or the capability of reproducing its text included in the insurer's claim file.

(2) If a claim is made on a health insurance policy and the claim involves a coordination of benefits issue to which OAR 836-020-0700 to 836-020-0765 apply, the time allowed in 836-020-0740 to an insurer for applying a coordination of benefit provision shall be added to the time period provided in section (1) of this rule.

(3) If a claim is denied for reasons other than those described in section (1) of this rule and is made by any other means than in writing, an appropriate notation shall be made in the insurer's claim file.

(4) If an insurer needs more time to determine whether the claim of a first party claimant should be accepted or denied, it shall so notify the claimant not later than the 30th day after receipt of the proofs of loss, giving the reason more time is needed. Forty-five days from the date of such initial notification and every 45 days thereafter while the investigation remains incomplete, the insurer shall notify the claimant in writing of the reason additional time is needed for investigation.

(5) An insurer shall not fail to settle claims of first party claimants on the grounds that responsibility for payment should be assumed by others, except as may be provided otherwise by the provisions of the insurance policy issued by the insurer.

(6) If an insurer continues negotiations for settlement of a claim directly with a claimant who is neither an attorney nor represented by an attorney until the claimant's rights may be affected by a statute of limitations or policy time limit, the insurer shall give the claimant written notice that the time limit may be expiring and may affect the claimant's rights. The notice shall be given to first party claimants not less than 30 days before, and to third party claimants not less than 60 days before, the date on which the insurer believes the time limit may expire.

(7) An insurer shall not make a statement that indicates that the rights of a third party claimant may be impaired if a form or release is not completed within a given period of time, unless the statement is given for the purpose of notifying the third party claimant of the provision of a relevant statute of limitations.

(8) Notwithstanding section (4) of this rule, for title insurance:

(a) The requirements in section (4) of this rule are suspended from the date the insurer arranges or agrees to legal representation of the insured, for the term of that representation, with respect to:

(A) A matter for which the insurer accepts a tender of defense; or

(B) A matter for which the insurer prosecutes an action or proceeding or does, or causes to be done, any other act to establish the title as insured or to prevent or reduce loss or damage to the insured.

(b) When an insurer initially notifies the claimant that more time is needed, the insurer:

(A) May specify a date later than 45 days but not later than 90 days for the next and any successive notification; and

(B) Shall notify the claimant in writing by the date specified whether additional time is needed and give the reason additional time is needed.

Or. Admin. Code § 836-080-0235

IC 2-1980, f. 5-8-80, ef. 6-1-80; ID 3-1998, f. & cert. ef. 2-10-98; ID 19-2006, f. & cert. ef. 9-26-06; ID 16-2010, f. & cert. ef. 8-19-10

Stat. Auth.: ORS 731.244

Stats. Implemented: ORS 746.230(1) & 746.240