California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 9 - Insurance Fraud › Article 2 - Special Investigative Unit › Section 2698.30 - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
As used in this article, the following definitions shall
					 apply:
(a) "Act" means any violation
				  of California Code of Regulations, Title 10, Chapter 5, Section
				  2698.30-42, inclusive.
(b) "Authorized governmental agency
				  (agencies)" shall have the same meaning as used in the Insurance Frauds
				  Prevention Act (IFPA).
(c) "Claims
				  handler" means every employee and agent of an insurer whose principal
				  responsibilities include the investigation, adjustment, settlement, and
				  resolution of claims.
(d)
				  "Commissioner" means the Insurance Commissioner of the State of
				  California.
(e) "Communication"
				  includes the referral of suspected insurance fraud to the Department of
				  Insurance and providing information and documents requested by the Fraud
				  Division.
(f) "Contracted entity"
				  means any entity with which an insurer contracts to perform SIU or integral
				  anti-fraud personnel duties or functions on behalf of the insurer. "Contracted
				  entity" includes subcontractors and sub-subcontractors contracted to perform
				  SIU or integral anti-fraud personnel duties or functions on behalf of the
				  insurer. The term "contracted entity" does not include the insurer's
				  affiliates, or subsidiaries, with which the insurer contracts to perform SIU or
				  integral anti-fraud personnel duties or functions on behalf of the insurer.
				  "Contracted entity" does not include entities with whom an insurer, or another
				  of the insurer's contracted entities, contracts to provide an expert opinion on
				  a medical, technical, or scientific topic, or perform a discreet, specific
				  investigative task such as surveillance, accident reconstruction, background
				  checks, scene inspections, social media checks, interviews, witness canvassing,
				  Arising Out of Employment/Course of Employment (AOE/COE) investigations,
				  activity checks, or database vendor services including, but not limited to, ISO
				  ClaimSearch, LexisNexis, and Accurint, on behalf of the insurer in connection
				  with the insurer's performance of its SIU or integral anti-fraud personnel
				  duties or functions. However, the immediately preceding sentence
				  notwithstanding, entities that (1) participate in the claims handling function
				  of the insurer, (2) make decisions on behalf of the insurer with respect to the
				  insurer's SIU or integral anti-fraud functions, or (3) contract with other
				  entities to perform SIU or integral anti-fraud duties or functions on behalf of
				  the insurer, are included within the meaning of the term "contracted
				  entity."
(g) "Department" means the
				  California Department of Insurance.
(h) "Fraud Division" means the California
				  Department of Insurance Fraud Division formerly known as the Bureau of
				  Fraudulent Claims.
(i) "Hearing"
				  means an adjudicative proceeding initiated by the Insurance Commissioner
				  pursuant to the provisions of California Insurance Code section
				  1875.24(d).
(j) "Inadvertent" means
				  unintentional.
(k) "Insurer" means
				  every insurer admitted to do business in this state except the following:
(1) Reinsurers.
(2) Title insurers.
(3) Fraternal fire insurers.
(4) Fraternal benefit societies.
(5) Firemen, policemen, or peace officer
				  benefit and relief associations.
(6) Grant and annuity societies.
(7) Home protection.