Illinois Administrative Code › Title 50 - INSURANCE › Part 919 - IMPROPER CLAIMS PRACTICE › Section 919.40 - Definitions/Explanations

Current through Register Vol. 48, No. 28, July 12, 2024
"Code" means the Illinois Insurance Code [215 ILCS 5 ].
"Company" means any licensee of the Department of Insurance,
				including health maintenance organizations.
"Days", for the purpose of this Part, means calendar
				days.
"Department" means the Illinois Department of Insurance.
"Director" means the Director of the Illinois Department of
				Insurance.
"Documentation" means all pertinent communications,
				transactions, notes and work papers. All such communications, transactions,
				notes and work papers shall be properly dated and compiled in sufficient detail
				in order to allow for the reconstruction of all pertinent events relative to
				each claim file. Documentation shall include but not be limited to bills,
				explanations of benefits and worksheets.
"First Party" means any individual, corporation, association,
				partnership, or other legal entity asserting a contractual right to payment
				under an insurance policy or insurance contract arising out of the contingency
				or loss covered by the policy or contract.
"Insured" means, for the purposes of life, accident and health
				insurance or other health care or service plans, the party named on a contract
				as the individual, corporation or association with legal rights to the benefits
				provided by the contract. This includes certificate holders or subscribers to a
				group contract and enrollees of a health maintenance organization, any other
				type of health care or service plans, or third party administrator. For
				purposes of property and casualty insurance, the party named on the contract is
				the insured.
"Non-Original Manufacturer" means any manufacturer other than
				the manufacturer of the original part.
"Notice of Availability of the Department of Insurance", as
				required by this Part, shall be no less informative than the following:
Part 919 of the Rules of the Illinois Department of Insurance
				requires that our company advise you that, if you wish to take this matter up
				with the Illinois Department of Insurance, it maintains a Consumer Division in
				Chicago at 122 S. Michigan Ave., 19th Floor,
				Chicago, Illinois 60603 and in Springfield at 320 West Washington Street,
				Springfield, Illinois 62767.
"Notification of Loss" means communication, as required by the
				policy or that is otherwise acceptable by the insurer, from a claimant or
				insured to the insurer that identifies the claimant or insured and indicates
				that a loss has occurred or is about to occur.
"Pertinent Communication", as used in Section 154.6(b) of the
				Code, means all correspondence, regardless of source or type, that is
				materially related to the handling of the claim.
"Policy", for the purpose of this Part, means a policy,
				certificate or contract issued to Illinois residents, including a certificate
				of enrollment into a health maintenance organization or any other type of
				health care or service plan.
"Private Passenger Automobile" means a vehicle insured under a
				policy of automobile insurance as defined in Section 143.13 of the Code.
"Prompt Investigation", as used in Section 154.6(c) of the Code
				, means all activities of the company related directly or indirectly to the
				determination of liability based on claims under the coverage afforded by the
				policy and shall be evidenced by a bonafide effort to communicate with all
				insureds and claimants when liability is reasonably clear within 21 working
				days after a notification of loss. Evidence of bonafide effort to communicate
				with insureds and claimants shall be maintained in the company's claim
				files.
"Reasonable Promptness", as used in Section 154.6(b) of the
				Code, means a maximum of 15 working days from receipt of communication from a
				claimant or insured.
"Replacement Crash Parts", for purposes of this Part, means
				sheet metal or synthetic parts, e.g., plastic, fiberglass, etc., that
				constitute the exterior of a motor vehicle, including inner and outer
				panels.
"Representative" means any person expressly authorized to act
				on behalf of the insurer and any employee of the insurer who acts or appears to
				act on behalf of the insurer in matters relating to claims, including but not
				limited to independent contractors while performing claim services at the
				direction of the company.
"Settlement of Claims", as used in Section 154.6(c) of the
				Code, shall pertain to all activities of the company or its representatives,
				relating directly or indirectly to the determination of the extent of
				liabilities due or potentially due under coverages afforded by the policy.
				Evidence of those activities shall be maintained in the company's claim
				files.
"Third Party" refers to any individual, corporation,
				association, partnership or other legal entity asserting a claim against any
				individual, corporation, partnership or other legal entity insured under a
				policy.