(1)(a) A notice of loss to an insurer, if required, is considered timely if made according to the terms of the policy, this rule, and Section 31A-21-312.(b) A notice of loss may be given to an insurer or an authorized agent.
(c) A notice of loss requirement may be waived by an authorized agent.
(d) The general business practice of an insurer when accepting a notice of loss shall be consistent for all policyholders.
(e) Within 15 days of receiving a notice of loss from a claimant, an insurer shall provide necessary claim forms, instructions, and reasonable assistance so the claimant can properly comply with the insurer's requirements for filing a claim.
(2)(a) A proof of loss to an insurer is considered timely if made according to the terms of the policy, this rule, and Section 31A-21-312.
(b) A proof of loss requirement may not be unreasonable and shall consider the circumstances surrounding a given claim.
R590-191-7. Minimum Standards for Prompt, Fair, and Equitable Benefit Determination and Settlement.
(1)(a) A benefit determination time period begins once an insurer receives a claim, regardless of whether all necessary information was filed with the original claim.
(b) If an insurer requires an extension due to a claimant's failure to submit necessary information, the time period for making a decision is tolled from the date the notice is sent to the claimant through:
(i) the date the claimant provides the necessary information; or
(ii) 48 hours after the end of the time period for the claimant to provide the additional information.
(2) Within 15 days of receiving a proof of loss from a claimant, an insurer shall:
(a) provide written acknowledgment of receipt of the proof of loss;
(b) request any necessary additional information from the claimant; and
(c) begin any necessary investigation of the claim, including requesting additional information from other parties having documentation or information relating to the claim.
(3) If no additional information or investigation is necessary under Subsection (2), an insurer shall provide the claim settlement and a written explanation of benefits to the claimant.
(4) Within 15 days of receiving any communication relating to a claim that reasonably suggests that a response is expected, an insurer shall substantively respond to the communication.
(5)(a) Within 30 days of receiving a proof of loss from a claimant, an insurer shall complete the investigation of the claim.
(b) If the investigation cannot reasonably be completed within 30 days, an insurer shall:
(i) establish, with adequate records, that the investigation could not be completed within 30 days of its receipt of the proof of loss;
(ii) communicate to the claimant, in writing, the reasons for the delay; and
(iii) continue to communicate in writing at least every 30 days until the claim is either settled or denied.
(6) Within 15 days of completing an investigation, an insurer shall:
(a) provide a claim settlement and a written explanation to the claimant; or
(b) provide, in writing, a denial of the claim and an explanation to the claimant of the reason for the denial.
(7) Closing a claim file without settlement is a denial and must be communicated, in writing, to the claimant according to this rule and the policy provisions.
(8) If recalculation or revisitation of a claim is necessary, the insurer shall comply with the initial claim handling process requirements described in this section.
R590-191-8. Unfair Claim Settlement Practices.
The commissioner finds that the following acts or general business practices are unfair claim settlement practices and are misleading, deceptive, unfairly discriminatory, overreaching, or an unreasonable restraint on competition:
(1) concealing from or failing to fully disclose to a claimant a benefit, limitation, exclusion, coverage, or other relevant provision of a contract or policy under which a claim is presented;
(2) denying or threatening to deny a claim, rescinding, canceling, or threatening to rescind or cancel coverage under a policy for a reason that is not clearly described in the contract or policy as a reason for denial, cancellation, or rescission;
(3) refusing to settle a claim without conducting a reasonable investigation;
(4) refusing to provide a written basis for denying a claim upon demand of a claimant;
(5) failing to provide a claimant with a written explanation of the evidence of an investigation or the claim file materials supporting a denial of a claim based on misrepresentation or fraud, if misrepresentation or fraud is the basis for the denial;
(6) compensating an employee, producer, or contractor an amount based on savings to the insurer due to reducing or denying a claim;
(7) making a claim settlement to a claimant without a statement or explanation that describes the coverage under which the settlement is made and how the settlement amount was calculated;
(8) failing to settle a claim following receipt of a proof of loss if liability is reasonably clear to influence another claim settlement under another portion of the policy or under another policy;
