Code of Massachusetts Regulations › 452 CMR - DEPARTMENT OF INDUSTRIAL ACCIDENTS › Title 452 CMR 7.00 - Practices By Insurers › Section 7.04 - Questionable Claims Handling Techniques/Patterns of Unreasonably Controverting Claims

Current through Register 1525, July 5, 2024
(1) Pursuant to
			 M.G.L. c. 23E, § 3(b)(8), except in the case of open cases active in the
			 Division of Dispute Resolution, the Department's Division of Administration
			 shall receive for investigation, on a form prescribed by the Department,
			 written allegations of questionable claims handling techniques or patterns of
			 unreasonably controverting claims by insurers, group self-insurers,
			 self-insurers, third party administrators, employers, or other entities,
			 including agents and brokers, handling workers' compensation claims.
(2) The Division of Administration shall
			 conduct an investigation, and shall provide the party against whom the
			 allegation is made an opportunity to respond in writing to the written
			 allegations within 30 days. The findings of said investigation shall be
			 reported to the Commissioner of Insurance, to the party making the allegation,
			 and to the respondent party, except that when a written allegation involves a
			 self-insured employer, a Department-certified vocational rehabilitation
			 provider, or a Department-approved utilization review agent, the findings shall
			 be forwarded to the Director of the Department or his or her designee rather
			 than to the Commissioner of Insurance.
(3) Questionable claims handling techniques
			 or patterns of unreasonably controverting claims shall include, but not be
			 limited to, techniques or patterns of practice which involve the following:
(a) misrepresenting pertinent facts or policy
			 provisions relating to coverage, entitlement to benefits under M.G.L. c. 152,
			 or any other material facts or provisions pursuant to M.G.L. c. 152, or for any
			 other purpose;
(b) failing to adopt
			 and utilize reasonable standards for the handling of claims consistent with the
			 provisions of M.G.L. c. 152, § 7;
(c) failing to effectuate prompt, fair, and
			 equitable adjustments of claims in which liability, causal relationship, and/or
			 extent of disability have become reasonably clear;
(d) failing to make payment or to provide the
			 written reason(s) for not doing so to a provider, as defined in
			 452 CMR 6.02:
Definitions,
who has submitted a request for reimbursement for
			 payment in accordance with the provisions of M.G.L. c. 152, §§ 13 and
			 30 and within 45 days of receipt of the request for reimbursement;
(e) prosecuting complaints or defending
			 against claims without reasonable grounds, including, but not limited to,
			 engaging in practices found violative of M.G.L. c. 152, § 14;
(f) delaying or prolonging the processing or
			 payment of requests for reimbursement, including, but not limited to, engaging
			 in repetitive, unnecessary, or otherwise unreasonable requests for the
			 submission of reimbursement or medical information;
(g) making payment to providers at rates
			 below those prescribed by the Massachusetts Rate Setting Commission, unless
			 said rates have been negotiated pursuant to M.G.L. c. 152, § 13;
(h) failing to undertake
			 utilization review pursuant to 452 CMR 6.00:
Utilization Review and
			 Quality Assessment,
including, but not limited to, failing to:
1. become a Department-approved utilization
			 review agent or, alternatively, contract with a Department-approved utilization
			 review agent;
2. maintain and
			 utilize adequate standards and procedures to monitor and coordinate utilization
			 review practices; or
3. comply with
			 the reporting requirements of
			 452 CMR
			 6.05(2);
(i) failing to conform
			 with the time frames and notice requirements set forth in M.G.L. c.
			 152;
(j) misrepresenting facts or
			 law to an experienced modified insured concerning settlement of a claim in
			 order to obtain the insured's written consent, or otherwise failing to obtain
			 such consent when so required by M.G.L. c. 152;
(k) failing to submit a revised statistical
			 unit report to the appropriate rating bureau within 60 days of a finding of
			 non-compensability, a recovery of previously paid workers' compensation
			 benefits from a third party, or reimbursements from the Workers' Compensation
			 Trust Fund for payments made pursuant to M.G.L. c. 152, § 65(2).
(l) failing to pay, in a timely manner,
			 referral fees due under the provisions of M.G.L. c. 152, § 10(5).