reglab/statecodes huggingface dataset:
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 17 - Actuarial Opinion and Memorandum Regulation › Section 2580.3 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) "Actuarial
				  Opinion" means the opinion of an Appointed Actuary regarding the adequacy of
				  the reserves and related actuarial items based on an Asset Adequacy Analysis
				  test in accordance with Section
				  2580.5 of this regulation and with
				  applicable Actuarial Standards of Practice.
(b) "Actuarial Standards Board" is the board
				  established by the American Academy of Actuaries to develop and promulgate
				  standards of actuarial practice.
(c) "Annual Statement" means that statement
				  required by Section
				  900 of the
				  Insurance Code to be filed by the Company with the office of the Commissioner
				  annually.
(d) "Appointed Actuary"
				  means any individual who is appointed or retained in accordance with the
				  requirements set forth in Subsection
				  2580.4(c) of this
				  regulation to provide the Actuarial Opinion and supporting memorandum as
				  required by Section
				  10489.15 of
				  the Insurance Code.
(e) "Asset
				  Adequacy Analysis" means an analysis that meets the standards and other
				  requirements referred to in Subsection
				  2580.4(d) of this
				  regulation.
(f) "Commissioner"
				  means the Insurance Commissioner of the State of California.
(g) "Company" means a life insurance company,
				  fraternal benefit society or reinsurer subject to the provisions of this
				  regulation.
(h) "Qualified Actuary"
				  means any individual who meets the requirements set forth in Subsection
				  2580.4(b) of this
				  regulation.
1. New
					 section filed 12-6-94; operative 1-5-95 (Register 94, No. 49).
2.
					 Amendment filed 12-27-2004; operative 1-1-2005 pursuant to Government Code
					 section
					 11343.4
					 (Register 2004, No. 53).
Note: Authority cited: Section
						10489.15,
						Insurance Code. Reference: Section
						10489.15,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 17 - Actuarial Opinion and Memorandum Regulation › Section 2580.4 - General Requirements

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  Submission of Statement of Actuarial Opinion.
(1) There is to be included on or attached to
				  Page 1 of the Annual Statement for each year beginning with the year in which
				  this regulation becomes effective the statement of an Appointed Actuary,
				  entitled "Statement of Actuarial Opinion," setting forth an opinion relating to
				  reserves and related actuarial items held in support of policies and contracts,
				  in accordance with Section
				  2580.5 of this
				  regulation.
(2) Upon written
				  request by the Company, the Commissioner may grant an extension of the date for
				  submission of the Statement of Actuarial Opinion.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 17 - Actuarial Opinion and Memorandum Regulation › Section 2580.5 - Statement of Actuarial Opinion Based on an Asset Adequacy Analysis

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) General
				  Description.
The statement of Actuarial Opinion submitted in accordance
					 with this section shall consist of:
(1) A paragraph identifying the Appointed
				  Actuary and his or her qualifications (see Paragraph 2580.5(b)(1));
(2) A scope paragraph identifying the
				  subjects on which an opinion is to be expressed and describing the scope of the
				  Appointed Actuary's work, including a tabulation delineating the reserves and
				  related actuarial items that have been analyzed for asset adequacy and the
				  method of analysis, (see Paragraph 2580.5(b)(2)) and identifying the reserves
				  and related actuarial items covered by the opinion that have not been so
				  analyzed;
(3) A reliance paragraph
				  describing those areas, if any, where the Appointed Actuary has deferred to
				  other experts in developing data, procedures or assumptions, (e.g., anticipated
				  cash flows from currently owned assets, including variation in cash flows
				  according to economic scenarios (see Paragraph 2580.5(b)(3)), supported by a
				  statement of each such expert in the form prescribed by Subsection
				  2580.5(e);
				  and
(4) An opinion paragraph
				  expressing the Appointed Actuary's opinion with respect to the adequacy of the
				  supporting assets to mature the liabilities (see Paragraph
				  2580.5(b)(6)).
(5) One or more
				  additional paragraphs will be needed in individual Company cases as follows:
(A) If the Appointed Actuary considers it
				  necessary to state a qualification of his or her opinion.
(B) If the Appointed Actuary must disclose an
				  inconsistency in the method of analysis or basis or asset allocation used at
				  the prior opinion date with that used for this opinion.
(C) If the Appointed Actuary must disclose
				  whether additional reserves as of the prior opinion date are released as of
				  this opinion date, and the extent of the release.
(D) If the Appointed Actuary chooses to add a
				  paragraph briefly describing the assumptions which form the basis for the
				  Actuarial Opinion.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 17 - Actuarial Opinion and Memorandum Regulation › Section 2580.7 - Statement of Actuarial Opinion Based on an Asset Adequacy Analysis. [Renumbered]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 section filed 12-6-94; operative 1-5-95 (Register 94, No. 49).
2.
					 Renumbering of former section
					 2580.7 to section
					 2580.5 filed 12-27-2004; operative
					 1-1-2005 pursuant to Government Code section
					 11343.4
					 (Register 2004, No. 53).
Note: Authority cited: Section
						10489.15,
						Insurance Code. Reference: Section
						10489.15,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 17 - Actuarial Opinion and Memorandum Regulation › Section 2580.8 - Description of Actuarial Memorandum Including an Asset Adequacy Analysis and Regulatory Asset Adequacy Issues Summary. [Renumbered]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 section filed 12-6-94; operative 1-5-95 (Register 94, No. 49).
2.
					 Renumbering of former section
					 2580.8 to section
					 2580.6 filed 12-27-2004; operative
					 1-1-2005 pursuant to Government Code section
					 11343.4
					 (Register 2004, No. 53).
Note: Authority cited: Section
						10489.15,
						Insurance Code. Reference: Section
						10489.15,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 17 - Actuarial Opinion and Memorandum Regulation › Section 2580.9 - Additional Considerations for Analysis. [Repealed]

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
1. New
					 section filed 12-6-94; operative 1-5-95 (Register 94, No. 49).
2.
					 Repealer of section, including renumbering of portions of former section
					 2580.9 to section
					 2580.6, filed 12-27-2004;
					 operative 1-1-2005 pursuant to Government Code section
					 11343.4
					 (Register 2004, No. 53).
Note: Authority cited: Section
						10489.15,
						Insurance Code. Reference: Section
						10489.15,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 17.2 - Actuarial Confidentiality and Conflict of Interest Regulation › Section 2581.1 - Purpose

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
These regulations are mandated by Section
					 10236.12 of
					 the California Insurance Code. The purpose of these regulations is to ensure
					 that independent actuaries, who are retained by the California Department of
					 Insurance to examine long-term care insurance rate filings, maintain the
					 confidentiality of long-term care insurance rate filings and proprietary
					 insurer information, and avoid actual or potential conflicts of
					 interest.
1. New
					 article 17.2 (sections
					 2581.1-2581.4) and section filed
					 2-26-2002; operative 3-28-2002 (Register 2002, No.
					 9).
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 17.2 - Actuarial Confidentiality and Conflict of Interest Regulation › Section 2581.2 - Maintenance of Confidentiality

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Before retaining an independent actuary for examination of
					 long-term care insurance rates, the Commissioner shall require a written
					 declaration by the actuary that:
1.
				  the actuary shall not disclose to another party, other than the California
				  Department of Insurance, and shall protect from unauthorized use, any
				  confidential information obtained in the course of examining long-term care
				  insurance rate filings, unless authorized to do so by the company or required
				  by law; and
2. the actuary shall
				  not disclose to another party and shall protect from unauthorized use, all
				  confidential information obtained from the California Department of Insurance
				  in the course of examining long-term care insurance rate filings.
With respect to this Section, "confidential information"
					 means information not in the public domain, including information of a
					 proprietary nature and information that is legally restricted from
					 circulation.
1. New
					 section filed 2-26-2002; operative 3-28-2002 (Register 2002, No.
					 9).
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 17.2 - Actuarial Confidentiality and Conflict of Interest Regulation › Section 2581.3 - Avoidance of Conflict of Interest

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Before retaining an independent actuary for examination of
					 long-term care insurance rate filings, the California Department of Insurance
					 shall require a written declaration by the actuary that:
1. the actuary will not perform professional
				  services involving an actual or potential conflict of interest unless:
(a) the actuary's ability to act fairly is
				  unimpaired;
(b) there has been
				  disclosure of the conflict to all present, or known prospective, clients or
				  employers of the actuary's services whose interests would be affected by the
				  conflict; and
(c) all such present,
				  or known prospective, clients or employers of the actuary's services have
				  expressly agreed to the performance of the services by the
				  actuary.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 17.2 - Actuarial Confidentiality and Conflict of Interest Regulation › Section 2581.4 - Billing of Actuarial Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The costs and expenses of all examinations by independent
					 actuaries of such long-term care insurance rate filings shall be paid in
					 accordance with California Insurance Code Sections
					 733(g)
					 and
					 736.
1. New
					 section filed 2-26-2002; operative 3-28-2002 (Register 2002, No.
					 9).
Note: Authority cited: Section
						10236.12,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 17.3 - Recognition of Preferred Mortality Tables for Use in Determining Minimum Reserve Liabilities › Section 2582 - Purpose

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The purpose of this article is to recognize and permit the
					 use of mortality tables that reflect differences in mortality between preferred
					 and standard lives in determining minimum reserve liabilities in accordance
					 with California Insurance Code Section
					 10489.2(a)
					 of California's "Standard Valuation Law," California Insurance Code Section
					 11136(b)(1)
					 of California's "Fraternal Benefit Societies" statutes, and California Code of
					 Regulations Title 10, Chapter 5, Subchapter 3, Article 12.3 "Valuation of Life
					 Insurance Policies," Sections
					 2542.4(a) and
					 2542.4(b).
1. New
					 article 17.3 (sections
					 2582-2582.3) and section filed
					 12-31-2010; operative 12-31-2010 pursuant to Government Code section
					 11343.4
					 (Register 2010, No. 53).
Note: Authority cited: Sections
						10489.2 and
						11136,
						Insurance Code. Reference: Sections
						10489.2 and
						11136,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 17.3 - Recognition of Preferred Mortality Tables for Use in Determining Minimum Reserve Liabilities › Section 2582.1 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) "2001 CSO
				  Mortality Table," incorporated by reference herein, means that mortality table,
				  consisting of separate rates of mortality for male and female lives, developed
				  by the American Academy of Actuaries CSO Task Force from the Valuation Basic
				  Mortality Table developed by the Society of Actuaries Individual Life Insurance
				  Valuation Mortality Task Force, and adopted by the National Association of
				  Insurance Commissioners ("NAIC") in December 2002. The 2001 CSO Mortality Table
				  is included in the
Proceedings of the NAIC (2nd Quarter 2002)
and supplemented by the 2001 CSO Preferred Class Structure Mortality Table
				  defined below in subsection (b). Unless the context indicates otherwise, the
				  "2001 CSO Mortality Table" includes both the ultimate form of that table and
				  the select and ultimate form of that table and includes both the smoker and
				  nonsmoker mortality tables and the composite mortality tables. It also includes
				  both the age-nearest-birthday and age-last-birthday bases of the mortality
				  tables. Mortality tables in the 2001 CSO Mortality Table include the following:
(1) "2001 CSO Mortality Table (F)" means that
				  mortality table consisting of the rates of mortality for female lives from the
				  2001 CSO Mortality Table.
(2) "2001
				  CSO Mortality Table (M)" means that mortality table consisting of the rates of
				  mortality for male lives from the 2001 CSO Mortality Table.
(3) "Composite Mortality Tables" means
				  mortality tables with rates of mortality that do not distinguish between
				  smokers and nonsmokers.
(4) "Smoker
				  and Nonsmoker Mortality Tables" means mortality tables with separate rates of
				  mortality for smokers and nonsmokers.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 17.3 - Recognition of Preferred Mortality Tables for Use in Determining Minimum Reserve Liabilities › Section 2582.2 - 2001 CSO Preferred Class Structure Mortality Table

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
At the election of the company, for each calendar year of
					 issue, for any one or more specified plans of insurance and subject to
					 satisfying the conditions stated in this article, the 2001 CSO Preferred Class
					 Structure Mortality Table may be substituted in place of the 2001 CSO Smoker or
					 Nonsmoker Mortality Table as the minimum valuation standard for policies issued
					 on or after January 1, 2007 and, subject to commissioner approval, for policies
					 issued prior to January 1, 2007 which were valued using the 2001 CSO Mortality
					 Table. No such election shall be made until the company demonstrates at least
					 20% of the business to be valued on this table is in one or more of the
					 preferred classes. A table from the 2001 CSO Preferred Class Structure
					 Mortality Table used in place of a 2001 CSO Mortality Table, pursuant to the
					 requirements of this article, will be treated as part of the 2001 CSO Mortality
					 Table only for purposes of reserve valuation pursuant to the requirements of
					 California Department of Insurance Bulletin No. 2003-05,
Recognition of
					 the 2001 CSO Mortality Table for Use in Determining Minimum Reserve Liabilities
					 and Nonforfeiture Benefits
(effective January 1, 2004), incorporated
					 by reference herein. Bulletin 2003-05 is applicable except as provided
					 specifically herein.
1. New
					 section filed 12-31-2010; operative 12-31-2010 pursuant to Government Code
					 section
					 11343.4
					 (Register 2010, No. 53).
Note: Authority cited: Sections
						10489.2 and
						11136,
						Insurance Code. Reference: Sections
						10489.2 and
						11136,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 17.3 - Recognition of Preferred Mortality Tables for Use in Determining Minimum Reserve Liabilities › Section 2582.3 - Conditions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) For each plan
				  of insurance with separate rates for preferred and standard nonsmoker lives, an
				  insurer may use the Super Preferred Nonsmoker, Preferred Nonsmoker, and
				  Residual Standard Nonsmoker tables to substitute for the nonsmoker mortality
				  table found in the 2001 CSO Mortality Table to determine minimum reserves. At
				  the time of election and annually thereafter, except for business valued under
				  the Residual Standard Nonsmoker Table, the appointed actuary shall certify
				  that:
(1) The present value of death benefits
				  over the next ten years after the valuation date, using the anticipated
				  mortality experience without recognition of mortality improvement beyond the
				  valuation date for each class, is less than the present value of death benefits
				  using the valuation basic table corresponding to the valuation table being used
				  for that class.
(2) The present
				  value of death benefits over the future life of the contracts, using
				  anticipated mortality experience without recognition of mortality improvement
				  beyond the valuation date for each class, is less than the present value of
				  death benefits using the valuation basic table corresponding to the valuation
				  table being used for that class.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 18 - The California Fair Plan Association › Section 2590 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
As used in this Article:
(a) "The Association" is as defined in
				  California Insurance Code Section
				  10091(a).
(b) "Basic Property Insurance" is as defined
				  in California Insurance Code Section
				  10091(c).
(c) "Brush Hazard Areas" are those areas
				  designated by the Insurance Services Office "(ISO") or its successor entity as
				  brush hazard areas subject to catastrophic brush fires.
(d) "Inner City Areas" are those specific
				  areas, which the Commissioner designates within the geographic or urban areas
				  under Insurance Code Section
				  10091(c)
				  that are underserved by the member insurers, except that Brush Hazard Areas are
				  not Inner City Areas.
(e) "Method"
				  refers to the method for proportionately relieving insurers from participation
				  in the Association pursuant to Insurance Code Section
				  10094.2 and
				  this article. A method is proportionate if the more an insurer has qualifying
				  premiums the greater that insurer's relief from participation in the
				  Association. Nothing in the Method shall preclude an insurer who qualifies from
				  being wholly relieved of its participation in the Association.
(f) "Qualifying Premiums" are those premiums
				  that a participating insurer derives from risks insured in brush hazard or
				  inner city areas as defined under Sections
				  2590(c) and (d)
				  above.
1. New
					 article 18 (sections
					 2590-2590.1) and section filed
					 11-24-99; operative 12-24-99 (Register 99, No.
					 48).
Note: Authority cited: Section
						10094.2,
						Insurance Code. Reference: Sections
						10090,
						10091 and
						10094.2,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 18 - The California Fair Plan Association › Section 2590.1 - Adoption of Method for Calculating Insurer Credits for Relief from Participation in the Association

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  The Association shall adopt and implement a fair and reasonable Method,
				  consistent with Insurance Code Section
				  10094.2 and
				  this article, that allows eligible insurers whole or partial relief from
				  participation in the Association. Under the Method, an insurer shall be
				  eligible for relief in proportion to the insurer's total premium writings in
				  the following categories, but credit for premium writings in these categories
				  need not be equally weighted:
(1) Basic
				  Property Insurance on risks located in Brush Hazard Areas;
(2) Basic Property Insurance on risks located
				  in Inner City Areas;
(3) Basic
				  Property Insurance on risks located in areas designated at the beginning of the
				  policy period as high or very high fire hazard severity zones as determined and
				  mapped by the Department of Forestry and Fire Protection, or very high fire
				  hazard severity zones as determined and mapped by the Department of Forestry
				  and Fire Portection pursuant to Section
				  51178 of the Government code;
				  and
(4) Business owners package
				  insurance on risks located in Inner City Areas.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 19 - Regulations for Enforcement Actions and Penalties › Section 2591 - Preamble

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The purpose of
				  this article is to meet the requirements of Insurance Code section
				  12921.1,
				  paragraph (a)(7). This statute pertains to violations of statutes or
				  regulations which are discovered in the investigation of consumer complaints
				  and requires that the commissioner establish a list of criteria to determine
				  which violations by insurers should be pursued through enforcement action and
				  to establish enforcement guidelines that set forth appropriate penalties for
				  violations based on the nature, severity, and frequency of the
				  violations.
(b) Pursuant to the
				  commissioner's authority to enforce the Insurance Code, this article shall also
				  apply to actions arising from findings generated by other regulatory activities
				  that allege violations of statutes or regulations. These activities include but
				  are not limited to market conduct examinations or other Department
				  investigations, examinations, or reviews of insurer conduct. This article is
				  intended to provide greater uniformity in enforcement and in the general
				  assessment of penalties imposed upon insurers.
1. New
					 article 19 (sections
					 2591-2591.4) and section filed
					 12-15-2003; operative 1-14-2004 (Register 2003, No.
					 51).
Note: Authority cited: Sections
						790.10 and
						12921.1,
						Insurance Code; CalFarm Insurance Company v. Deukmejian, 48 Cal.3d 805 (1989);
						and 20th Century Insurance Company v. Garamendi, 8 Cal. 4th 216 (1994).
						Reference: Sections
						704.7,
						769.86,
						789.3,
						790.035,
						790.036,
						790.07,
						790.10,
						1858.07,
						1858.1,
						1858.3,
						1859.1,
						1861.14,
						10140.1,
						10140.5,
						10149.1,
						10199.7,
						10234.3,
						10509.9,
						11756,
						12414.25
						and
						12921.1,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 19 - Regulations for Enforcement Actions and Penalties › Section 2591.1 - Scope and Purpose

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  This article applies to those provisions of the California Insurance Code that
				  allow the commissioner discretion in pursuing a penalty against an insurer or
				  in setting the penalty amount. The Department shall apply the criteria provided
				  in Section
				  2591.3 of this article to
				  determine whether a particular violation warrants an enforcement action and to
				  determine the amount of penalty within the applicable statutory range of
				  penalties. The provisions of this article are appropriate for determining the
				  penalty imposed in those cases which are resolved through settlement.
(b) Enforcement action.
(1) For purposes of this article, enforcement
				  action means any action based on an allegation by the Department that an
				  insurer has committed a violation to which a penalty provision set forth in any
				  of the statutes listed in subdivision (c) below applies, over the course of
				  which action one or both of the following is to occur:
(A) The execution of a Stipulation and
				  Consent Order or other settlement document.
(B) The issuance of a Notice of
				  Noncompliance, Order to Show Cause, Accusation, Statement of Issues, or other
				  legal pleading.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 19 - Regulations for Enforcement Actions and Penalties › Section 2591.2

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The Department shall examine the violations committed by
					 the insurer. The Department shall take into consideration the criteria listed
					 in Section
					 2591.3 and any other relevant
					 considerations to determine if the seriousness of the insurer's act warrants an
					 enforcement action. If after a review of those criteria the Department
					 determines that an enforcement action is warranted, the Department shall take
					 into consideration the criteria listed in Section
					 2591.3 and any other relevant
					 considerations to determine an appropriate penalty for each act in violation of
					 the law from within the applicable statutory penalty range or ranges. In
					 addition to the actual penalty amount, the Department may also recover its
					 costs associated with the enforcement action, including but not limited to
					 attorneys' fees.
1. New
					 section filed 12-15-2003; operative 1-14-2004 (Register 2003, No.
					 51).
Note: Authority cited: Sections
						790.10 and
						12921.1,
						Insurance Code; CalFarm Insurance Company v. Deukmejian, 48 Cal.3d 805 (1989);
						and 20th Century Insurance Company v. Garamendi, 8 Cal. 4th 216 (1994).
						Reference: Sections
						704.7,
						769.86,
						789.3,
						790.035,
						790.036,
						790.07,
						790.10,
						1858.07,
						1858.1,
						1858.3,
						1859.1,
						1861.14,
						10140.1,
						10140.5,
						10149.1,
						10199.7,
						10234.3,
						10509.9,
						11756,
						12414.25,
						12921 and
						12921.1,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 19 - Regulations for Enforcement Actions and Penalties › Section 2591.3

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
In determining that an enforcement action should be pursued
					 and in selecting the appropriate amount of the penalty from the applicable
					 range of penalty amounts that could be assessed, the Department shall
					 consider:
(a) The nature of the
				  violation, including but not limited to adverse actions such as overcharge of
				  premium, unlawful denials or terminations of coverage, placement in a program
				  or tier with a higher rate level or less coverage than the most favorable for
				  which the insured would qualify, misrepresentations of terms, unlawful denial
				  or delay of claims, unreasonably low claims offers or settlements, improper
				  sharing of personal information, acts of unfair competition and acts of unfair
				  discrimination.
(b) The severity of
				  the violation.
(1) Severity of the violation
				  includes but is not limited to:
(A) the extent
				  of harm revealed through a consumer complaint or otherwise brought to the
				  attention of the Department;
(B)
				  the amount of premium overcharge or undercharge;
(C) the amount of underpayment of a
				  claim;
(D) a comparison of the
				  length of the delay to the time reasonably necessary or legally required to
				  conduct the process or transaction;
(E) the significance of the amount of premium
				  involved in relation to the total premium for the coverage; and
(F) the significance of the amount of
				  underpayment of the loss settlement offer or final settlement involved in
				  relation to the total loss settlement determined to be
				  reasonable.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 19 - Regulations for Enforcement Actions and Penalties › Section 2591.4

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Equal
				  consideration need not be given to each criterion described in Section
				  2591.3. The Department shall
				  determine which criteria are relevant under the circumstances and shall
				  determine the appropriate consideration to be given to those criteria. Neither
				  inapplicability of one or more criteria nor absence of harm shall mitigate the
				  effect of any relevant criterion.
(b) The determinations made regarding the
				  criteria that are relevant for purposes of the decision as to whether an
				  enforcement action is to be pursued may differ from the determinations made in
				  the same case regarding the criteria that are relevant for purposes of the
				  decision as to the appropriate penalty. Likewise, the amount of consideration
				  any relevant criterion is to receive for purposes of determining whether an
				  enforcement action is to be pursued may, in the same case, differ from the
				  amount of consideration, if any, which that criterion is to receive for
				  purposes of determining the appropriate penalty.
(c) In determining whether to pursue an
				  enforcement action and in determining an appropriate penalty, the Department
				  may, in circumstances it deems appropriate, consider matters not listed in
				  Section 2591.3. When such other
				  considerations enter into the settlement process, the basis for those
				  considerations will be stated during the course of any settlement
				  negotiations.
(d) The provisions of
				  this article do not affect the commissioner's discretion to take any other
				  measures such as seeking an order requiring specific corrective action, a
				  hearing in accordance with statute, or the suspension or revocation of an
				  entity's license or certificate of authority. Nothing in this article shall, in
				  any manner, abridge or constitute a waiver of the attorney-client, work
				  product, deliberative process or other privilege, or other right of
				  confidentiality, afforded by rule, regulation, case law or statute, including
				  but not limited to the California Evidence Code and the Federal Rules of
				  Evidence.
1. New
					 section filed 12-15-2003; operative 1-14-2004 (Register 2003, No.
					 51).
Note: Authority cited: Sections
						790.10 and
						12921.1,
						Insurance Code; CalFarm Insurance Company v. Deukmejian, 48 Cal.3d 805 (1989);
						and 20th Century Insurance Company v. Garamendi, 8 Cal. 4th 216 (1994).
						Reference: Sections
						704.7,
						769.86,
						789.3,
						790.035,
						790.036,
						790.07,
						790.10,
						1858.07,
						1858.1,
						1858.3,
						1859.1,
						1861.14,
						10140.1,
						10140.5,
						10149.1,
						10199.7,
						10234.3,
						10509.9,
						11756,
						12414.25
						and
						12921.1,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 20 - Standards Applicable to Workers' Compensation Claims Adjusters and Medical Billing Entities and Certification of those Standards by Insurers › Section 2592 - Authority and Purpose

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
These regulations are promulgated pursuant to authority
					 granted to the Insurance Commissioner under the provisions of Section
					 11761 of
					 the California Insurance Code. The purpose of these regulations is to set forth
					 the minimum standards of training, experience, and skill that workers'
					 compensation claims adjusters, including adjusters working for medical billing
					 entities, must possess to perform their duties with regard to workers'
					 compensation claims and to specify how insurers must meet and certify those
					 standards to the Insurance Commissioner.
1. New
					 article 20 (sections
					 2592-2592.14) and section filed
					 1-23-2006; operative 2-22-2006 (Register 2006, No.
					 4).
Note: Authority cited: Section
						11761,
						Insurance Code. Reference: Section
						11761,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 20 - Standards Applicable to Workers' Compensation Claims Adjusters and Medical Billing Entities and Certification of those Standards by Insurers › Section 2592.02 - Training Required for Claims Adjusters and Medical-Only Claims Adjusters

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Every insurer
				  shall require all claims adjusters and medical-only claims adjusters who handle
				  workers' compensation claims on the insurer's behalf, other than those who are
				  defined in subdivisions (f) and (g) of Section
				  2592.01, to be trained pursuant to
				  these subparagraphs:
(1) The insurer shall
				  require at least 160 hours of training for claims adjusters, at least 120 hours
				  of which shall be conducted in a classroom with an instructor. The insurer
				  shall require at least 80 hours of training for medical-only claims adjusters,
				  at least 50 hours of which shall be conducted in a classroom with an
				  instructor. Any training not conducted in a classroom with an instructor may be
				  done on the job under the supervision of an instructor or an experienced claims
				  adjuster.
(2) A medical-only claims
				  adjuster who has completed 80 hours of training pursuant to this section may be
				  designated as a claims adjuster upon completion of 80 additional hours of
				  workers' compensation claims training, 70 hours of which shall be in a
				  classroom with an instructor, provided that such training is completed within
				  six months of the claims adjuster beginning to adjust claims that include more
				  than medical benefits.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 20 - Standards Applicable to Workers' Compensation Claims Adjusters and Medical Billing Entities and Certification of those Standards by Insurers › Section 2592.03 - Curriculum

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The course of
				  study required by Section
				  2592.02 for claims adjusters shall
				  include, but not be limited to, the following topics:
(1) Historical overview of the workers'
				  compensation system.
(2)
				  Organizational structure of the system.
(3) The workers' compensation insurance
				  policy, its forms and endorsements, insurance principles of
				  compensation.
(4) Concepts and
				  terminology.
(5) Benefit
				  provisions.
(6)
				  Compensability.
(7) Notice
				  requirements.
(8) Temporary
				  disability.
(9) Permanent
				  disability, including evaluation and rating.
(10) Death benefits.
(11) Return to work and vocational
				  rehabilitation.
(12) Cumulative
				  trauma.
(13) Serious and willful
				  misconduct.
(14) Workers'
				  Compensation Appeals Board procedures, forms, hearings, and
				  penalties.
(15)
				  Investigation.
(16)
				  Fraud.
(17) Medical
				  terminology.
(18) Knowledge and use
				  of utilization guidelines (American College of Occupational and Environmental
				  Medicine or other guidelines approved by the Administrative Director of the
				  Division of Workers' Compensation.)
(19) Medical evidence.
(20) Medical dispute resolution (Qualified
				  Medical Examiners, spinal surgery second opinions, pre-designation of
				  physicians, independent medical reviewers, utilization review.)
(21) Fee schedules.
(22) Liens.
(23) Apportionment.
(24) Subrogation.
(25) Reserving.
(26) Ethical issues.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 20 - Standards Applicable to Workers' Compensation Claims Adjusters and Medical Billing Entities and Certification of those Standards by Insurers › Section 2592.05 - Designation

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A Designation
				  shall be provided by the insurer to any person who successfully completes the
				  claims adjuster, medical-only claims adjuster, or medical bill reviewer
				  training required by sections
				  2592.02 and
				  2592.03 or section
				  2592.04, respectively. The
				  Designation for a claims adjuster, medical-only claims adjuster or a medical
				  bill reviewer shall be in the form specified in Section
				  2592.10 or
				  2592.11, respectively.
(b) An Experienced Claims Adjuster or
				  Experienced Medical-Only Claims Adjuster Designation shall be provided by the
				  insurer to a person as defined in Section
				  2592.01(f) or
				  (g), respectively. The Experienced Claims
				  Adjuster or Experienced Medical-Only Claims Adjuster Designation shall be in
				  the form specified in Section
				  2592.12.
(c) An Experienced Medical Bill Reviewer
				  Designation shall be provided by the insurer to a person as defined in Section
				  2592.01(h). The
				  Experienced Medical Bill Reviewer Designation shall be in the form specified in
				  Section 2592.13.
(d) An insurer shall provide to the claims
				  adjuster, medical-only claims adjuster or medical bill reviewer a
				  Post-Designation Training Form that states the course and hours taken for the
				  post-designation training following the completion of the required training.
				  The Post-Designation Training Form shall be on the form specified in Section
				  2592.14.
(e) A medical billing entity may provide
				  medical bill reviewer and experienced medical bill reviewer Designations and
				  Post-Designation Training Forms to its employees or agents that meet the
				  requirements of this article so long as the insurer using the medical billing
				  entity confirms that the medical billing entity has met all requirements of
				  this article and obtains copies of all records required by this
				  article.
1. New
					 section filed 1-23-2006; operative 2-22-2006 (Register 2006, No.
					 4).
Note: Authority cited: Section
						11761,
						Insurance Code. Reference: Section
						11761,
						Insurance Code.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 20 - Standards Applicable to Workers' Compensation Claims Adjusters and Medical Billing Entities and Certification of those Standards by Insurers › Section 2592.06 - Maintenance of Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) An
				  insurer shall maintain copies of the Designation forms pertaining to trained
				  and experienced claims adjusters, medical-only claims adjusters and medical
				  bill reviewers in its employ or acting on its behalf, notwithstanding whether
				  or not that person was designated by it or was employed or trained by or on
				  behalf of another insurer or a medical billing entity, as long as the claims
				  adjuster, medical-only claims adjuster, or medical bill reviewer is in its
				  employ or acting on its behalf and thereafter for five (5) years.
(b) An insurer shall maintain copies of the
				  Post-Designation Training Forms as long as the claims adjuster, medical-only
				  claims adjuster, or medical bill reviewer is in its employ or acting on its
				  behalf, notwithstanding whether or not that person received post-designation
				  training by that insurer or was employed or trained by or on behalf of another
				  insurer or medical billing entity, and thereafter for five (5) years.
(c) If a trained or experienced claims
				  adjuster, medical-only claims adjuster, or medical bill reviewer is employed by
				  or works on behalf of an insurer that did not designate him or her, the insurer
				  that did designate the claims adjuster, medical-only claims adjuster, or
				  medical bill reviewer shall send copies of the Designation Forms to the current
				  insurer within 20 working days after a request for the Designation Forms has
				  been received.
(d) All insurers
				  shall maintain a record of all courses given or taken by claims adjusters,
				  medical-only claims adjusters, or medical bill reviewers to comply with this
				  article. The record shall include:
(1) The
				  name and business address of all students, along with the beginning and ending
				  date of the training of the student and a statement of whether or not the
				  student has completed the training in all topic areas required to be
				  covered.
(2) A complete description
				  of the curriculum, including all topics covered with a detailed statement of
				  how much time was spent training students in each topic, the name of the entity
				  providing the instruction, and the name of the instructor or instructors and
				  any persons who instructed under the direction of the
				  instructor.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 20 - Standards Applicable to Workers' Compensation Claims Adjusters and Medical Billing Entities and Certification of those Standards by Insurers › Section 2592.07 - Certification and Submission of Documents

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Each insurer shall submit to the
				  commissioner annually by July 1 of each year a document certifying the
				  following:
(1) the total number of persons
				  adjusting claims on its behalf;
(2)
				  the total number of claims adjusters and medical-only claims adjusters who are
				  trained or experienced;
(3) the
				  percentage of the claims adjusters and medical-only claims adjusters who are
				  trained or experienced;
(4) all
				  persons adjusting claims on behalf of the insurer are designated to do so or
				  are in training; and
(5) the course
				  of instruction provided for training of all claims adjusters and medical-only
				  claims adjusters meets all requirements of this article and that all claims
				  adjusters and medical-only claims adjusters have attended training for the
				  required number of hours to be qualified to adjust workers' compensation
				  claims.
The document, which shall be on the form specified in
					 Section 2592.08, shall be signed under
					 penalty of perjury by the person or executive officer responsible for the
					 insurer's claims operations. The commissioner shall publish the information
					 contained in this document on the Department of Insurance public
					 website.
California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 3 - Insurers › Article 20 - Standards Applicable to Workers' Compensation Claims Adjusters and Medical Billing Entities and Certification of those Standards by Insurers › Section 2592.08 - Insurer Annual Certification Form-Claims Adjusters and Medical-Only Claims Adjusters

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
ANNUAL CERTIFICATION OF CLAIMS ADJUSTERS AND
					 MEDICAL-ONLY CLAIMS ADJUSTERS
To the Insurance Commissioner of the State of California
					 Pursuant to California Insurance Code Section
					 11761 and
					 California Code of Regulations, Title 10, Sections
					 2592.02 and
					 2592.07
As the person or officer responsible for the claims
					 operation of:
______________________________
(Name of Insurer)
[] Insurance Company
[] Self-Insured Employer
[] Third-Party
								Administrator
(Check One)
I hereby certify the following regarding California
					 workers' compensation claims:
1. The total number of persons adjusting
				  claims on this insurer's behalf is: __________.
2. The total number of experienced or trained
				  claims adjusters and medical-only claims adjusters adjusting claims on the
				  insurer's behalf is: __________.
3.
				  The percentage of experienced or trained claims adjusters and medical-only
				  claims adjusters adjusting claims on the insurer's behalf is:
				  __________%
4. All persons
				  adjusting claims on behalf of this insurer are designated to do so or are in
				  training.
5. The course of
				  instruction provided for training of all claims adjusters and medical-only
				  claims adjusters meets all requirements set forth in Article 20 (commencing
				  with section
				  2592) of Subchapter 3, Chapter 5,
				  Title 10, California Code of Regulations, and that all claims adjusters and
				  medical-only claims adjusters have attended training for the required number of
				  hours to be qualified to adjust workers' compensation claims.
I certify under the penalty of perjury under the laws
					 of the State of California that the foregoing is true and
					 correct:
___________________________
___________________________
(Date and Place)
(Signature)
Name of person certifying (print or type):
Title of person certifying:
Business address:
1. New
					 section filed 1-23-2006; operative 2-22-2006 (Register 2006, No.
					 4).
Note: Authority cited: Section
						11761,
						Insurance Code. Reference: Section
						11761,
						Insurance Code.