Missouri Code of State Regulations › Title 20 - DEPARTMENT OF COMMERCE AND INSURANCE › Division 100 - Insurer Conduct › Chapter 1 - Improper or Unfair Claims Settlement Practices › Section 20 CSR 100-1.010 - Definitions

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule sets forth definitions used in the
				  rules in this division to aid in the interpretation of various terms and
				  phrases.
(1) As used in the
				Unfair Claims Settlement Practices Act at sections
				375.1000
				to
				375.1018,
				RSMo and in the regulations promulgated pursuant thereto-
(A) "Insurance producer" or "producer," any
				individual, corporation, association, partnership or other legal entity
				authorized to represent an insurer with respect to a claim;
(B) "Claim,"-
1. A request or demand for payment of a loss
				which may be included within the terms of coverage of an insurance policy;
				or
2. A request or demand for any
				other payment under the policy, such as for the return of unearned premium or
				nonforfeiture benefits;
(C) "Claimant," any-
1. First-party claimant, including a
				subscriber under any plan providing health services;
2. Third-party claimant; or
3. Person or entity submitting a claim on
				behalf of any insured and includes the claimant's designated legal
				representative and a member of the claimant's immediate family designated by
				the claimant;
(D)
				"First-party claimant," any individual, corporation, association, partnership
				or other legal entity asserting a right to payment arising out of the
				occurrence of a contingency or loss covered by an insurance policy;
(E) "Insurer," has the same meaning as in
				section
				375.1002(2),
				RSMo;
(F) "Investigation," all
				activities of an insurer directly or indirectly related to the determination of
				liabilities under coverages afforded by an insurance policy;
(G) "Notification of claim," any
				notification, whether in writing or by other means acceptable under the terms
				of an insurance policy to an insurer or its insurance producer, by a claimant,
				which reasonably apprises the insurer of the facts pertinent to a
				claim;
(H) "Third-party claimant,"
				any individual, corporation, association, partnership or other legal entity
				asserting a claim against any individual, corporation, association, partnership
				or other legal entity insured under an insurance policy;
(I) "Insurance policy," any insurance
				contract, certificate of insurance or contract under which health services are
				to be provided; and
(J) "Time error
				rate," refers to any one (1) of the following:
1. Acknowledgment time error rate, the
				percentage of claims in which the insurer has performed an act described in
				section
				375.1007(2),
				RSMo, or violated
				20 CSR
				100-1.030;
2. Investigation time error rate, the
				percentage of claims in which the insurer has performed an act described in
				section
				375.1007(3),
				RSMo, or violated
				20 CSR
				100-1.030; or
3. Determination time error rate, the
				percentage of claims in which the insurer has performed an act described in
				section
				375.1007(7),
				RSMo, or violated
				20
				CSR 100-1.050.