2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 19. Insurance Information and Privacy Protection › Part 1. General Provisions › 33-19-104. Definitions

33-19-104. Definitions.
As used in this chapter, the following definitions apply:
(1) (a) "Adverse underwriting decision" means any of the following actions with respect to insurance transactions involving insurance coverage that are individually underwritten:
(i) a declination of insurance coverage;
(ii) a termination of insurance coverage;
(iii) failure of an insurance producer to apply for insurance coverage with a specific insurance institution that the insurance producer represents and that is requested by an applicant;
(iv) in the case of a property or casualty insurance coverage:
(A) placement by an insurance institution or insurance producer of a risk with a residual market mechanism, an unauthorized insurer, or an insurance institution that specializes in substandard risks; or
(B) the charging of a higher rate on the basis of information that differs from that which the applicant or policyholder furnished;
(v) in the case of a life, health, or disability insurance coverage, an offer to insure at higher than standard rates.
(b) The following actions are not adverse underwriting decisions, but the insurance institution or insurance producer responsible for their occurrence shall nevertheless provide the applicant or policyholder with the specific reason or reasons for their occurrence:
(i) the termination of an individual policy form on a class or statewide basis;
(ii) a declination of insurance coverage solely because the coverage is not available on a class or statewide basis; or
(iii) the rescission of a policy.
(2) "Affiliate" or "affiliated" means a person who directly, or indirectly through one or more intermediaries, controls, is controlled by, or is under common control with another person.
(3) "Applicant" means a person who seeks to contract for insurance coverage other than a person seeking group insurance that is not individually underwritten.
(4) "Consumer report" means any written, oral, or other communication of information bearing on a natural person's credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living that is used or expected to be used in connection with an insurance transaction.
(5) "Consumer reporting agency" means a person who:
(a) regularly engages, in whole or in part, in the practice of assembling or preparing consumer reports for a monetary fee;
(b) obtains information primarily from sources other than insurance institutions; and
(c) furnishes consumer reports to other persons.
(6) "Control", including the terms "controlled by" or "under common control with", means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or nonmanagement services, or otherwise, unless the power is the result of an official position with or corporate office held by the person.
(7) "Declination of insurance coverage" means a denial, in whole or in part, by an insurance institution or insurance producer of requested insurance coverage.
(8) "Individual" means a natural person who:
(a) regarding property or casualty insurance, is a past, present, or proposed named insured or certificate holder;
(b) regarding life, health, or disability insurance, is a past, present, or proposed principal insured or certificate holder;
(c) is a past, present, or proposed policyowner;
(d) is a past or present applicant;
(e) is a past or present claimant; or
(f) derived, derives, or is proposed to derive insurance coverage under an insurance policy or certificate subject to this chapter.
(9) "Institutional source" means a person or governmental entity that provides information about an individual to an insurance producer, insurance institution, or insurance-support organization, other than:
(a) an insurance producer;
(b) the individual who is the subject of the information; or
(c) a natural person acting in a personal capacity rather than a business or professional capacity.
(10) "Insurance function" means claims administration, claims adjustment and management, fraud investigation, fraud prevention, underwriting, loss control, ratemaking functions, reinsurance, risk management, case management, disease management, quality assessment, quality improvement, provider credentialing verification, utilization review, peer review activities, subrogation, grievance procedures, insurance transactions, internal administration of compliance and policyholder service functions, and technical, administrative, or professional services related to the provision of the functions described in this subsection.
(11) (a) "Insurance institution" means a corporation, association, partnership, reciprocal exchange, interinsurer, Lloyd's insurer, fraternal benefit society, or other person engaged in the business of insurance, including health maintenance organizations, and health service corporations as defined in 33-30-101.
(b) Insurance institution does not include insurance producers or insurance-support organizations.
(12) "Insurance producer" means an insurance producer as defined in 33-17-102 and 33-30-311.
(13) (a) "Insurance-support organization" means a person who assembles or collects information about natural persons for the purpose of providing the information to an insurance institution or insurance producer for insurance transactions, including:
(i) the furnishing of consumer reports or investigative consumer reports to an insurance institution or insurance producer for use in connection with an insurance transaction; or
(ii) the collection of personal information from insurance institutions, insurance producers, or other insurance-support organizations for the purpose of detecting or preventing fraud, material misrepresentation, or material nondisclosure in connection with insurance underwriting or insurance claim activity.
(b) The following persons are not insurance-support organizations for purposes of this chapter: insurance producers, government institutions, medical care institutions, and medical professionals.
(14) "Insurance transaction" means a transaction involving insurance primarily for personal, family, or household needs, rather than for business or professional needs, that entails:
(a) the determination of an individual's eligibility for an insurance coverage, benefit, or payment; or
(b) the servicing of an insurance application, policy, contract, or certificate.
(15) "Investigative consumer report" means a consumer report or portion of a consumer report containing information about a natural person's character, general reputation, personal characteristics, or mode of living obtained through personal interviews with the person's neighbors, friends, associates, acquaintances, or others who may have knowledge concerning this type of information.
(16) "Licensee" means:
(a) an insurance institution, insurance producer, or other person who is licensed or required to be licensed, authorized or required to be authorized, or registered or required to be registered pursuant to this title; or
(b) a surplus lines insurer.
(17) "Medical care institution" means a facility or institution that is licensed to provide health care services to natural persons, including but not limited to health maintenance organizations, home health agencies, hospitals, medical clinics, public health agencies, rehabilitation agencies, and skilled nursing facilities.
(18) "Medical professional" means a person who is licensed or certified to provide health care services to natural persons, including but not limited to a chiropractor, clinical dietitian, clinical psychologist, dentist, nurse, occupational therapist, optometrist, pharmacist, physical therapist, physician, podiatrist, psychiatric social worker, or speech-language pathologist.
(19) "Medical record information" means personal information that:
(a) relates to an individual's physical or mental condition, medical history, medical claims history, or medical treatment; and
(b) is obtained from a medical professional or medical care institution, from the individual, or from the individual's spouse, parent, or legal guardian.
(20) "Person" means a natural person, corporation, association, partnership, or other legal entity.
(21) "Personal information" means any individually identifiable information gathered in connection with an insurance transaction from which judgments can be made about an individual's character, habits, avocations, finances, occupation, general reputation, credit, health, or any other personal characteristics. Personal information includes an individual's name and address and medical record information but does not include privileged information.
(22) "Policyholder" means a person who:
(a) in the case of individual property or casualty insurance, is a present named insured;
(b) in the case of individual life, health, or disability insurance, is a present policyowner; or
(c) in the case of group insurance that is individually underwritten, is a present group certificate holder.
(23) "Pretext interview" means an interview during which a person, in an attempt to obtain information about a natural person, performs one or more of the following acts:
(a) pretends to be someone else;
(b) pretends to represent a person not in fact being represented;
(c) misrepresents the true purpose of the interview; or
(d) refuses to provide identification upon request.
(24) "Privileged information" means any individually identifiable information that:
(a) relates to a civil or criminal proceeding involving an individual; and
(b) is collected in connection with or in reasonable anticipation of a claim for insurance benefits or civil or criminal proceeding involving an individual. Information otherwise meeting the requirements of privileged information under this subsection is considered personal information under this chapter if it is disclosed in violation of 33-19-306.
(25) "Residual market mechanism" means an association, organization, or other entity defined or described in 61-6-144.
(26) "Separate, written authorization" means an individual's written authorization that is:
(a) obtained by the recipient of personal or privileged information that has been disclosed to the recipient pursuant to 33-19-306(10), (11), (14), (15), and (17); and
(b) separate from any written authorization obtained by the disclosing insurance institution, insurance producer, or insurance-support organization.
(27) "Termination of insurance coverage" or "termination of an insurance policy" means either a cancellation or nonrenewal of an insurance policy, in whole or in part, for any reason other than the failure to pay a premium as required by the policy.
(28) "Unauthorized insurer" means an insurance institution that has not been granted a certificate of authority by the commissioner to transact the business of insurance in this state.
History: En. Sec. 4, Ch. 580, L. 1981; amd. Sec. 1, Ch. 713, L. 1989; amd. Sec. 149, Ch. 42, L. 1997; amd. Sec. 1, Ch. 258, L. 1997; amd. Sec. 1, Ch. 212, L. 1999; amd. Sec. 2, Ch. 341, L. 2001; amd. Sec. 1, Ch. 385, L. 2003.