California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 7.4 - Consumer Complaints › Section 2694 - Criteria for Determining Whether a Consumer Complaint is Justified

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A consumer
				complaint shall be deemed justified within the meaning of California Insurance
				Code section
				12921.1(b)
				where it meets any one or more of the following criteria:
(1) the Department determines that the
				licensee's act, acts, omission or omissions were in noncompliance with a
				specific provision or provisions of the California Insurance Code, California
				Code of Regulations, or other applicable laws and/or regulations;
(2) the Department determines that the
				licensee's act, acts, omission or omissions were in contravention of an
				approved rate filing or filings;
(3) the Department determines that the
				licensee's act, acts, omission or omissions were in contravention of the
				licensee's rules, policies, procedures or guidelines as relates to sales,
				marketing, advertising, underwriting, rating, claims and/or customer service,
				including rate manual filings, underwriting guidelines and/or other filings,
				statements or guidelines either submitted to the Department or to which the
				Department would have access during a market conduct examination and the
				Department determines that there was no substantial justification for deviation
				from such rules, policies, procedures or guidelines on the facts presented. For
				purposes of this subsection, all time restrictions or requirements for reply,
				response, or other legally required insurer action, shall be measured as
				against applicable time restrictions or parameters established in the
				California Insurance Code, California Code of Regulations, or other applicable
				laws and/or regulations.
(4) the
				Department determines that the licensee's act, acts, omission or omissions were
				in contravention of, or were otherwise inconsistent with, a provision or
				provisions of the insurance policy, contract, bond, or other agreement entered
				into by the relevant parties;
(5)
				the Department determines that after receiving a written or documented oral
				communication related to a claim, benefit underwriting or rating transaction,
				from a policyholder, insured, applicant, third party claimant, beneficiary,
				principal, or other party with a legitimate interest in the transaction, where
				that communication reasonably suggests that a response is expected, the
				licensee has failed to respond or did not provide a complete response, based on
				the facts then known by the licensee, within the applicable time restrictions
				established in the California Insurance Code, California Code of Regulations,
				other applicable laws and/or regulations or, in the absence of such
				restrictions, the licensee fails to respond within 15 days. A complete response
				is defined as one that addresses all issues raised and includes copies of any
				documentation needed to support the licensee's position.
(6) the Department determines that the
				specific facts surrounding the complaint as against an insurer merit remedial
				action within the authority of the Commissioner.