reglab/statecodes huggingface dataset:
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-31 - Payment of Claims

Current through 2024-29, July 17, 2024
Upon receipt of a notice of claim for benefits under a policy
				  or certificate of long-term care insurance delivered or issued for delivery in
				  this State, and after the insurer has sent the written statement required by
				   24-A M.R.S.A.
				  §5083(1) and received
				  the information identified in
				  24-A M.R.S.A.
				  §5083(2), a long-term
				  care insurer shall pay or deny the claim within 30 days, except as otherwise
				  permitted by this section. If the insurer is unable to decide the claim because
				  more information is needed, it may request necessary additional documentation,
				  consistent with Subsection A, with sufficient detail to permit the insured to
				  understand and respond. The written request must be provided by the insurer
				  within 10 business days after receipt of the notice of claim. For purposes of
				  this section, "insured" includes the insured's authorized
				  representative.
A.
Documentation
The documentation an insurer may require of an insured
				  following the submission of a claim for benefits under a policy or certificate
				  of long-term care insurance is as follows:
(1) A brief statement by or on behalf of the
				insured describing the basis of the claim for benefits;
(2) A signed release permitting the insurer
				to obtain personal health information about the insured pursuant to the federal
Health Insurance Portability and Accountability Act of
				1996
;
(3) A statement from
				the insured's physician, including the appropriate diagnosis and a treatment
				and care plan for the insured;
(4)
				A statement from the long-term care provider rendering services to the insured,
				including an itemized bill for services, the provider's license number, and any
				daily nursing notes;
(5) A copy of
				any power of attorney executed by the insured; and
(6) Other information that the insurer
				determines is reasonably necessary to evaluate before making a determination on
				the claim and is not readily available from sources other than the
				insured.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-32 - Appealing a Claims Denial

Current through 2024-29, July 17, 2024
A.
Representation
. For purposes of this section and for section
				33, "insured" includes the insured's
				authorized representative.
B.
Notice
. An insurer shall provide clear written notice to the
				insured of any claims denial. The notice shall include:
(1) The reason or reasons for the
				decision;
(2) Reference to the
				specific contract provision on which the decision is based;
(3) A description of any additional material
				or information necessary for the insured to perfect the claim and an
				explanation of why such material or information is necessary;
(4) The insured's right to internal appeal in
				accordance with subsection C, including instructions and time limits for
				initiating the appeal, and the right to submit new or additional information
				relating to the claims denial with the appeal request;
(5) The insured's right, after completion of
				the insurer's internal appeal process, to have the claims denial reviewed under
				the independent review process in accordance with Section
				33 if the claims denial is eligible
				for external review, and the right to file a complaint with the superintendent
				after completion of at least one level of the insurer's internal review
				process.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-33 - External Review

Current through 2024-29, July 17, 2024
A.
Notice of
				External Review
. If the insurer's claims denial eligible for external
				review is upheld after completion of the insurer's internal appeal process
				outlined in section
				32, the insurer shall provide a
				written description of the insured's right to request an external review. The
				notice must include:
(1) A description of the
				external review procedure and the requirements for making a request for
				external review;
(2) A statement
				informing the insured how to request assistance from the insurer in filing a
				request for external review;
(3) A
				statement informing the insured of the right to participate in the external
				review proceeding by teleconference or other reasonable means, to obtain and
				submit material in support of the claim, to ask questions of the insurer, and
				to have outside assistance; and
(4) A statement informing the insured of the
				right to seek assistance or file a complaint with the bureau and the toll-free
				number for the bureau.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-34 - Transition

Current through 2024-29, July 17, 2024
A. Within four months after the effective
				date of the 2015 amendments to this rule, every insurer shall file with the
				superintendent any new forms or contract provisions, and all revisions to
				existing forms or contracts, which it will be using as a result of the
				amendments.
B. Every insurer
				required to file forms with the superintendent and subject to this rule shall
				send all applicable forms and amended contract provisions to existing
				individual and group contract holders within 60 days after the first billing
				date after the form or contract provision has been approved by the
				superintendent.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Section 031-425-35 - Effective Date

Current through 2024-29, July 17, 2024
This rule is effective July 1, 2004. Unless otherwise noted,
				  the 2007 amendments are effective December 15, 2007. The 2015 amendments are
				  effective March 30, 2015.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 425 - LONG-TERM CARE INSURANCE › Appendix 031-425-D

Current through 2024-29, July 17, 2024
Producer's or Insurer's Suitability Letter to
				  Applicant:
Dear [Applicant]:
Your recent application for long-term care insurance included
				  a "personal worksheet," which asked questions about your finances and your
				  reasons for buying long-term care insurance. For your protection, state law
				  requires us to consider this information when we review your application to
				  avoid selling a policy to those who may not need coverage.
[Your answers indicate that long-term care insurance may not
				  meet your financial needs. We suggest that you review the information provided
				  along with your application, including the booklet the "Shopper's Guide to
				  Long-term Care Insurance" and the page titled "Things You Should Know Before
				  Buying Long-term Care Insurance." The Maine Bureau of Insurance also has
				  information about long-term care insurance, and may be able to refer you to a
				  counselor free of charge who can help you decide whether to buy this
				  policy.]
[You chose not to provide any financial information for us to
				  review.]
Drafting Note:
Choose the paragraph that
				  applies.
We have suspended our final review of your application. If,
				  after careful consideration, you still believe this policy is what you want,
				  check the appropriate box below and return this letter to us within the next 60
				  days. We will then continue reviewing your application and issue a policy if
				  you meet our medical standards.
If we do not hear from you within the next 60 days, we will
				  close your file and not issue you a policy. You should understand that you will
				  not have any coverage until we hear back from you, approve your application and
				  issue you a policy.
Please check one box and return in the enclosed
				  envelope.
[]
Yes
, [although my worksheet indicates that
				  long-term care insurance may not be a suitable purchase,] I wish to purchase
				  this coverage. Please resume review of my application.
Drafting Note:
Delete the phrase in brackets if
				  the applicant did not answer the questions about income.
[]
No,
I have decided not to buy a policy at
				  this time.
__________________________________________
				  ______________________________
APPLICANT'S SIGNATURE DATE
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter 1 - GENERAL PROVISIONS › Section 031-440-1-1 - Purpose

Current through 2024-29, July 17, 2024
The purpose of this chapter is to establish clear and
					 comprehensive rules governing the operation of the workers' compensation
					 insurance residual market.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter 1 - GENERAL PROVISIONS › Section 031-440-1-2 - Authority

Current through 2024-29, July 17, 2024
This chapter is adopted pursuant to the authority granted
					 by
					 24-A M.R.S.A.
					 §§212 and
					 2386(5),
					 and P.L. 1995, ch. 289, § 19(2).
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter 1 - GENERAL PROVISIONS › Section 031-440-1-4 - Other Applicable Rules

Current through 2024-29, July 17, 2024
The operation of the residual market shall be subject to
					 the following provisions in addition to applicable statutes and the rules
					 contained in this chapter.
A. Chapter
				  450. Insurance Bureau Rules Chapter 450, Workers' Compensation Insurance
				  Experience Rating.
B. Chapter 460.
				  Insurance Bureau Rules Chapter 460, Workers' Compensation Statistical Recording
				  and Reporting.
C. Chapter 470.
				  Insurance Bureau Rules Chapter 470, Workers' Compensation Insurance Premium
				  Audits.
D. Other Provisions. All
				  applicable workers' compensation insurance manual rules, uniform plans, forms,
				  and rates and rating rules approved by the Superintendent pursuant to 24-A
				  M.R.S.A., Chapter 25.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter 1 - GENERAL PROVISIONS › Section 031-440-1-5 - Definitions

Current through 2024-29, July 17, 2024
For purposes of this chapter, the following terms are
					 defined as stated.
A. "Board" means
				  the Board of Governors of the Maine Workers' Compensation Residual Market
				  Pool.
B. ''Bureau" means the Maine
				  Bureau of Insurance.
C. "Manager"
				  means the manager appointed by the Board to perform the functions specified in
				  this chapter concerning the operation of the residual market.
D. "Plan" means the plan of operation for the
				  residual market its set forth in this chapter.
E. "Pool" means the Maine Workers'
				  Compensation Residual Market Pool.
F. "Superintendent" means the Maine
				  Superintendent of Insurance.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter II - MAINE WORKERS' COMPENSATION RESIDUAL MARKET POOL › Section 031-440-II-1 - Pool Established

Current through 2024-29, July 17, 2024
There is hereby established as part of the residual market
					 mechanism the Maine Workers' Compensation Residual Market Pool, an
					 unincorporated association.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter II - MAINE WORKERS' COMPENSATION RESIDUAL MARKET POOL › Section 031-440-II-2 - Purpose

Current through 2024-29, July 17, 2024
The purpose of the Pool is to provide reinsurance for all
					 workers' compensation residual market policies. Every residual market policy
					 issued to an employer by a member is reinsured effective at 12:01 a.m. on the
					 date on which the policy becomes effective, and the reinsurance applies during
					 the period that the policy is in effect. The reinsurance provided by the Pool
					 shall apply only to workers' compensation policies, including those coverages
					 set forth in Subchapter 1, Section 3 of this Rule.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter II - MAINE WORKERS' COMPENSATION RESIDUAL MARKET POOL › Section 031-440-II-3 - Membership

Current through 2024-29, July 17, 2024
The Pool consists of all Insurers, as defined in the
					 Workers' Compensation Residual Market Deficit Resolution and Recovery Act,
					  24-A M.R.S.A.
					 §2392(11), that were
					 authorized to provide workers' compensation insurance in Maine at any time
					 between January 1, 1988 and December 31, 1992. By virtue of that authority, all
					 Pool members remain bound by the plan of operation of the workers' compensation
					 residual market mechanism for the duration of the Pool's existence. Each group
					 of affiliated companies that is considered a single "Insurer" for purposes of
					 the Deficit Resolution and Recovery Act is considered a single member of the
					 Pool and is entitled to a single vote in membership meetings on any matter on
					 which that member is eligible to vote.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter II - MAINE WORKERS' COMPENSATION RESIDUAL MARKET POOL › Section 031-440-II-5 - Termination of Membership by Insolvency

Current through 2024-29, July 17, 2024
A. Pool
				  obligations. In the event any member company shall be adjudicated insolvent,
				  membership of such company in the Pool shall be deemed terminated at the time
				  of such adjudication of insolvency.
The Pool shall have the option, after the insolvency,
					 to:
(1) pay to the trustee, receiver,
				  liquidator, rehabilitator or other appropriate representative, all sums for
				  which such insolvent company shall have become liable upon risks to to which
				  are reinsured by the Pool, less all sums which are the obligation of the
				  insolvent company as a former member of the Pool. including, but not limited
				  to, an appropriate percentage of all assessments against the insolvent member
				  and all unearned premium distributions, and also less all unearned premium,
				  outstanding ceded premium and unearned servicing carrier allowances retained by
				  the insolvent company; or
(2)
				  terminate the obligation of the Pool to such insolvent company to pay through
				  such insolvent company or its representative losses and expenses for which the
				  insolvent company shall have become liable upon risks to which these Rules
				  apply. If this option is exercised, the Board shall make arrangements with the
				  plan manager pursuant to which all risks which have been assigned to and are
				  being serviced by such insolvent member shall be reassigned for servicing. In
				  lieu of being paid through the insolvent company or its representative, such
				  payments shall be made through the member or members assigned to service the
				  risks of the insolvent company; the Board shall have authority to make proper
				  provision, and upon such terms as it shall deem appropriate, for payment of the
				  expenses of servicing of such reassigned risks. Payment -made on account of
				  such risks, including expenses for the servicing thereof, shall be apportioned
				  ratably among the remaining members of the Pool in accordance with the method
				  provided for the apportioning of assessments.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter II - MAINE WORKERS' COMPENSATION RESIDUAL MARKET POOL › Section 031-440-II-6 - Meetings and Voting Rights of Members

Current through 2024-29, July 17, 2024
A. Regular
				  meetings. The Pool shall meet annually during the month of June at such place
				  as the Board may determine, subject to the Superintendent's approval. If the
				  annual meeting for any year shall not be duly held, the Board shall cause a
				  special meeting of the membership to be held as soon thereafter as possible, in
				  lieu of and for the purpose of such annual meeting, and all proceedings of such
				  special meetings shall have the same force as if taken at the regular annual
				  meeting.
B. Special meetings.
				  Special meetings of the members nay be called at any time by the Chairman or
				  the Superintendent and special meetings shall be called by the Chairman upon
				  the written request of three members of the Pool.
C. Notice of meetings. Except as otherwise
				  provided by this rule, notice of all annual and special meetings shall be given
				  or caused to be given by the Chairman, in writing, mailed or delivered to or by
				  telegram directed to each member at the latest address appearing upon the
				  records of the Pool or by telephone communication to any executive officer of
				  such member company. All members shall be provided thirty days notice of the
				  annual meeting. If notice of meetings of members, other than the annual
				  meeting, is given by writing and mailed to the member, such notice shall be
				  placed in the nail not less than five days prior to the meeting. If notice of
				  meetings of members, other than the annual meeting, is given by telegram or
				  telephone communication, it shall be so given not less that two days prior to
				  the meeting.
D. Quorum. Members
				  present or represented at any meeting shall constitute a quorum.
E. Powers. The purpose of any special meeting
				  shall be stated in the notice thereof ; but at all such meetings and at annual
				  meetings, members may consider and act upon all matters brought before
				  them.
F. Repealed as of November
				  27, 1995.
G. Proxies. Members may
				  be represented at any meeting by proxy. Members may record their votes by mail
				  on written propositions and such votes shall have the same standing as if cast
				  by such members in person or by proxy.
H. Minutes of meetings. Minutes of all
				  meetings of the Pool and of the Board shall be sent to all Pool members, all
				  Board members, and the Superintendent.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter II - MAINE WORKERS' COMPENSATION RESIDUAL MARKET POOL › Section 031-440-II-7 - Board of Governors

Current through 2024-29, July 17, 2024
A. Powers. The
				  Board of Governors of the Pool shall have the following powers and duties:
(1) to establish such operational standards
				  for the Pool as are necessary to the extent such standards are not inconsistent
				  with these rules or Maine law;
(2)
				  to designate a Plan Manager;
(3) to
				  monitor and enforce the performance of obligations imposed upon the Plan
				  Manager and servicing carriers by this rule and Maine law;
(4) to elect such officers as are necessary
				  for the operation of the Pool;
(5)
				  to maintain necessary records;
(6)
				  to sue or be sued; and
(7) such
				  other powers and duties as are set forth by these rules and those necessary and
				  proper to fulfill its responsibilities under Maine law.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter II - MAINE WORKERS' COMPENSATION RESIDUAL MARKET POOL › Section 031-440-II-8 - Indemnification

Current through 2024-29, July 17, 2024
A. Any person made or threatened to be made a
				  party to any legal action because such person was a member, or a servicing
				  carrier, or served on the Board or other committee or was an officer or
				  employee of the Pool shall be indemnified against all judgments, fines, amounts
				  paid in settlement, reasonable costs and expenses including attorney's fees and
				  any other liabilities that may be incurred as a result of such action, or
				  threatened action, except in relation to matters as to which he is adjudged to
				  be liable by reason of willful misconduct in the performance of his duties or
				  obligations to the Pool and, with respect to any criminal actions, except when
				  such person had reasonable cause to believe that his conduct was unlawful. Such
				  indemnification shall be provided whether or not such person is a member or a
				  servicing carrier or is holding office or is employed at the time of such
				  action. Such indemnification shall not be exclusive of other rights such person
				  may have and shall pass to the successors, heirs, executors or administrators
				  of such person. The termination of any such civil or criminal action, by
				  judgment, settlement, conviction or upon a plea of nolo contendere, or its
				  equivalent, shall not in itself create a presumption that any such person was
				  liable by reason of willful misconduct or that he had reasonable cause to
				  believe that his conduct was unlawful. If any such legal action is compromised,
				  it must be with the approval of the Board of the Pool; provided, however, the
				  Board of the Pool may delegate to the manager of the Pool the authority to
				  approve any compromise of financial liability requiring payment by the Pool
				  which is less than an amount as may be fixed from time to time by the Board. No
				  indemnification shall be provided as to any:
(1) payments made to the Pool pursuant to
				   24-A M.R.S.A.
				  §§2393 -
				  2394,
				  including payments made to any other party pursuant to an assignment under
				   24-A M.R.S.A.
				  §2393(1)(C)(2);
(2) costs and expenses of any kind incurred
				  in responding to a request for such payments; or
(3) costs and expenses of any kind, relating
				  in any way to the collection of such payments, incurred by an insurer that is a
				  party to an agreement authorized by
				   24-A M.R.S.A.
				  §2393(1)(A)(3) or
				  2393(1)(B)(6).
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter II - MAINE WORKERS' COMPENSATION RESIDUAL MARKET POOL › Section 031-440-II-9 - Administration

Current through 2024-29, July 17, 2024
The Board shall designate a Plan manager. The Plan manager
					 shall be responsible for monitoring all actuarial activities of the Plan and
					 for the provision of actuarial services necessary in the conduct of the Plan's
					 affairs, and shall be responsible for the handling, recording, accounting and
					 reporting of all Plan financial transactions. The Plan manager's
					 responsibilities shall include, but not be limited to, the following:
A. Repealed as of November 5, 1995.
B. Repealed as of November 5,
C. Accounts. The maintenance of deposit
				  accounts for holding funds and securities of the Pool consistent with the
				  provisions of section 16 of this subchapter;
D. Enforcement and reporting. The enforcement
				  of adherence to these rules by all members, and the reporting of members who do
				  not adhere to these rules to the Board and the Superintendent;
E. Reporting forms. The requiring of certain
				  forms to be used by member insurers for the periodic reporting to the Plan
				  manager of all data deemed relevant by the Plan manager, and to advise the
				  Superintendent whenever any insurer has failed to provide such a report within
				  thirty (30) days after its due date;
F. Legal actions. The maintenance of legal
				  actions in the name of the Pool when necessary for collection of debts owed to
				  the Pool or otherwise for the enforcement of such other rights as may inure to
				  the Pool and as directed by the Board;
G. Assignments. Processing of applications
				  for coverage and the making of servicing assignments where appropriate;
				  and
H. Monitoring and enforcement.
				  Monitoring and enforcement of servicing performance and data reporting
				  standards applicable to servicing carriers and implementation of such
				  enforcement mechanisms as are adopted by the Board.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter II - MAINE WORKERS' COMPENSATION RESIDUAL MARKET POOL › Section 031-440-II-11 - Collection and Remittance of Premium to Pool

Current through 2024-29, July 17, 2024
A.
				  Report and Payment requirement. On or before the 15th day of February, May,
				  August, and November of each year, each servicing carrier shall report to the
				  Pool all premium written and remit to the Pool all premium received, retaining
				  that portion of premium equal to its servicing fee, commission payments, and
				  paid losses. Assessments, other than guaranty fund assessments, and premium
				  taxes on all premiums collected shall be paid by the servicing carrier as part
				  of its expense.
B. Limited
				  liability of Pool. The Pool shall not be required to reimburse any servicing
				  carrier if loss of its servicing fee results from its failure to collect
				  premiums owed unless the servicing carrier has made a diligent collection
				  effort in accordance with the service performance standards of this chapter and
				  payment has been approved by the Pool manager.
C. Return Premiums. Servicing carriers shall
				  be promptly reimbursed by the Pool for any return premiums paid to insureds
				  which had previously been remitted to the Pool.
D. Insolvent servicing carrier: subrogation
				  rights. In the event of the insolvency of a servicing carrier, the Pool shall
				  automatically be subrogated to the rights of the servicing carrier to collect
				  further premiums due or to become due on risks assigned to it, and the insured
				  shall be protected in any payment of such premiums made to or upon the order of
				  the Pool. Any premiums received by the insolvent servicing carrier after such
				  insolvency shall be received in trust for the Pool and shall be promptly paid
				  over to the Pool, except that the servicing carrier may retain that part of any
				  servicing fee which has been earned up to the date of receipt. Any premiums so
				  received by the Pool shall be applied to the payment of losses, and an
				  accounting of such premiums shall be made to the insolvent carrier or its legal
				  representatives in connection with any refund.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter II - MAINE WORKERS' COMPENSATION RESIDUAL MARKET POOL › Section 031-440-II-12 - Payment of Losses and Pool Expenses

Current through 2024-29, July 17, 2024
A.
				  Reporting and payment of losses. The servicing carrier shall pay all losses
				  accruing on risks assigned to it as each loss becomes due and payable. On or
				  before the 15th day of February, May, August, and November of each year, each
				  servicing carrier shall report to the Plan manager all claims arising and
				  losses paid to the end of the preceding quarter on account of risks assigned to
				  it together with the then estimated value of all claims outstanding. For
				  purposes of this rule, losses shall include assessments levied against
				  servicing carriers by the Maine Insurance Guaranty Association with respect to
				  the workers' compensation insurance account authorized by
				   24-A M.R.S.A.
				  §4436, sub-§ 1.
If losses paid exceed premiums written, less servicing fees
					 and producer fees, then within thirty days after the receipt of such report or
					 within the Plan shall reimburse each such servicing carrier for the losses paid
					 by such servicing carrier.
B. Pool general expenses. Expenses incurred
				  by the Pool in the administration of its affairs, and not allocable directly to
				  any residual market risk, shall be paid from the general funds of the Pool. A
				  record shall be kept of all such expenses and the Plan manager shall provide to
				  the Board and to the Superintendent a written accounting of such expenditures
				  at the end of each quarter. Except with respect to claims, the cost of the
				  interpretation of physical and X-ray examinations of employees in assigned dust
				  hazard risks, provided the employer pays for the making of such examinations,
				  shall be a proper charge against, and shall be paid from, the general funds of
				  the Pool. Payments by the Pool shall be limited to the following:
1) the Pool's administration
				  expense;
2) reimbursement for
				  losses paid .under assigned risk policies;
3) return premiums on such
				  policies;
4) payment of such
				  refunds as way be allowed;
5)
				  reasonable expenses incurred by Board members while performing Board business;
				  and
6) reasonable and necessary
				  amounts charged for the collection of any part of any premium on any assigned
				  risks, provided that advance written approval to incur such collection costs is
				  obtained in each case from the Pool manager. Such approval shall be given when
				  it reasonably appears that diligent effort to collect the premium due has been
				  made by the member in the regular course of business and has been ineffective.
The Pool shall not assume for payment, and shall not be
					 liable to pay, any expenses of any nature incurred by members except as
					 provided herein.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter II - MAINE WORKERS' COMPENSATION RESIDUAL MARKET POOL › Section 031-440-II-13 - Residual Market Deficits; availability of funds

Current through 2024-29, July 17, 2024
In order to give notice to Pool members and the
					 Superintendent of whether any surcharge, or the failure to surcharge, will
					 result in cash deficits for the Pool during any quarter, the Pool manager shall
					 certify quarterly to the Superintendent anticipated premium, investment income,
					 losses, and expenses.
Whenever any such report indicates a temporary cash
					 inadequacy is likely to occur in the Pool, the Board shall arrange short-term
					 debt financing for the Pool in order to ensure that the Pool can meet its loss
					 and expense obligations as they become due. Whenever such short-term debt
					 financing is not available, the manager will notify the Board and the
					 Superintendent. The Board shall be allowed ten days to take appropriate action
					 to resolve the situation. If the situation is resolved, the Board shall advise
					 the Superintendent. If the problem is not resolved or if the Board waives the
					 ten day period, the Superintendent shall take appropriate action.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter II - MAINE WORKERS' COMPENSATION RESIDUAL MARKET POOL › Section 031-440-II-16 - Accounting and Records

Current through 2024-29, July 17, 2024
A. Adequate system
				  required. There shall be established and maintained by the Pool an adequate
				  accounting system applicable to member companies, servicing entities and the
				  Pool recognizing income received and expenses to be administered by the Pool.
				  Not less frequently than each quarter, servicing entities shall remit to the
				  Plan manager any written premiums which exceed those paid expenses and losses
				  which are properly chargeable to residual market risk policies. Such funds
				  shall be remitted to the Plan manager within 45 days following the close of the
				  quarter reported upon.
Funds so received by the Plan manager shall be invested and
					 the principal and interest thereon shall be available for redistribution to
					 servicing entities based upon a reasonable projection of their cash needs,
					 which shall be substantiated and revised quarterly. The Board shall establish
					 an investment policy in accordance with the prudent man standard, recognizing
					 the Plan manager's fiduciary capacity with respect to such funds.
Funds in the possession of servicing entities shall be
					 invested at an investment rate no less than the median yield for servicing
					 carrier insurers and shall be credited to the account of the Pool in any period
					 when a service carrier's residual market operating results produce a positive
					 fund balance.
B. Right to
				  inspect. The Board and/or any designated representative thereof shall have the
				  right at all reasonable times to inspect the books, records and files of the
				  servicing carrier so far as they pertain to the operations of the Plan, and
				  shall have the right to copy or abstract such books, records and files at the
				  Plan's expense.
If an additional claims examination is deemed necessary by
					 the Board as a result of advice received from a general audit or examination
					 such audit or examination shall be performed at the expense of the Pool. The
					 servicing carrier shall bear all expenses of any state insurance department
					 audit or examination.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter II - MAINE WORKERS' COMPENSATION RESIDUAL MARKET POOL › Section 031-440-II-17 - Applications

Current through 2024-29, July 17, 2024
For purpose of application to the 1988 plan, a renewal
					 offer by any servicing carrier retaining a license to write workers'
					 compensation regarding a policy reinsured in the 1987 Maine residual market
					 shall be deemed sufficient application to the 1988 Plan. A policy reinsured in
					 the 1987 Maine residual market written by a company no longer retaining a
					 license to write workers' compensation and for which a legal notice of
					 nonrenewal has been issued can only be reissued in the 1988 reinsurance Pool
					 through application to the 1988 plan in accordance with normal initial
					 application procedures.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter IV - SERVICING CARRIER PERFORMANCE STANDARDS › Section 031-440-IV-1 - General Standards

Current through 2024-29, July 17, 2024
Carriers receiving assignments shall provide a high quality
					 service, at a level comparable to that customarily provided by the insurance
					 industry to similar risks in the voluntary market. Any services necessary as a
					 result of regulatory or statutory requirements shall automatically apply. The
					 standards set forth in this subchapter prescribe the minimum acceptable in the
					 residual market.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter IV - SERVICING CARRIER PERFORMANCE STANDARDS › Section 031-440-IV-2 - Disability Management

Current through 2024-29, July 17, 2024
A. Disability
				  Control
(1) Maximum medical improvement
				  (MMI): The servicing carrier shall take appropriate steps to establish and
				  document MMI in each case file for partial incapacity cases with dates of
				  injury before October 17, 1991.
(i) MMI shall
				  be established by decree, by formal agreement, by the payment of a permanent
				  impairment award, or by strong medical evidence.
(ii) If MMI has not been established for a
				  partial incapacity case, the case file shall contain a documented plan
				  including discussion of specific measures by which the servicing carrier
				  intends to establish MMI with the Workers' Compensation Board.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter IV - SERVICING CARRIER PERFORMANCE STANDARDS › Section 031-440-IV-3 - Litigation Management

Current through 2024-29, July 17, 2024
A. Servicing
				  carriers shall properly prepare all controverted cases, and cases petitioned
				  for additional or subsequent ruling, before conference, hearing, or trial.
				  Preparation shall include but not be limited to the following:
(1) The carrier shall make a pre-litigation
				  offer for the purpose of establishing the "prevail standard" baseline for the
				  payment of legal fees, or explain in the file why it has chosen not to do
				  so;
(2) Complete pretrial
				  preparation in the areas at issue, such as coverage, liability,
				  medical;
(3) Have available all
				  necessary lay and professional witnesses or their depositions before formal
				  hearing or trial;
(4) Have medical
				  reports and opinions and witnesses available and ready for testimony or
				  deposition if trial encompasses issues of extent of disability and/or
				  permanency, depending on statutory requirements;
(5) Servicing carriers shall expeditiously
				  pursue the case through the mediation and hearing process, as appropriate.
				  Where appropriate, servicing carriers shall pursue settlement negotiations at
				  any point during the dispute resolution process;
(6) Servicing carriers shall base all
				  settlements of permanency or compromise on sound claims judgment consistent
				  with liability and medical evidence developed, in accordance with the law and
				  benefit structure;
(7) Servicing
				  carriers shall deliver sufficient file material on a timely basis to the
				  attorney or other person handling the case to allow for adequate preparation
				  for conference, hearing, or trial;
(8) After settlement, the servicing carrier
				  shall file a settlement report which adequately and accurately explains the
				  amount paid.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter IV - SERVICING CARRIER PERFORMANCE STANDARDS › Section 031-440-IV-4 - Reserving Practices

Current through 2024-29, July 17, 2024
A. Performance
				  Standards:
(1) Servicing carriers shall
				  establish timely, and to the fullest extent possible accurate, medical and
				  indemnity loss cost estimates commensurate with all factors known and
				  developed;
(2) Estimates of
				  reserves shall be revised whenever payments are made or developments occur that
				  cause changes to the ultimate loss projections;
(3) In reporting estimates on fatal and
				  permanent total cases, servicing carriers shall use tables authorized by the
				  Superintendent of Insurance;
(4)
				  Reserve estimates shall reasonably consider all contingencies involved in a
				  claim, including but not limited to survival and mortality, recovery and
				  morbidity, remarriage, return to work, escalation, and the time value of
				  money.
(5) Reserving of Pool cases
				  shall use consistent methodologies. Servicing carriers shall ensure that these
				  practices are followed consistently within their internal organizations among
				  claims adjusters, supervisors, and managers. Carriers shall have their
				  reserving practices documented in a way that will ensure they are consistently
				  applied, and shall make these documents available for review by the Pool at the
				  Board's request.
(6) Servicing
				  carriers shall keep the Pool apprised of changes in methodologies on an ongoing
				  basis.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter IV - SERVICING CARRIER PERFORMANCE STANDARDS › Section 031-440-IV-5 - Financial Reporting

Current through 2024-29, July 17, 2024
A. Carriers shall
				  ensure that all payments of Pool claims and all reimbursement requests to the
				  Pool are adequately documented and maintained in sufficient detail and format
				  to permit verification of all amounts that roll-up into the Pool's accounting
				  records.
B. The Board shall conduct
				  an annual financial review of servicing carrier claim payments, reimbursement
				  requests to the Pool, and case reserves, in accordance with audit program
				  requirements. The review shall include a review of actual claim files.
				  Appropriate sampling procedures may be used in conducting the claim file
				  review. The review shall include the following areas:
(1) Conformity with generally accepted and
				  statutory accounting practices;
(2)
				  Consistency of accounting and reserving methods;
(3) Timeliness of recording
				  transactions;
(4) Appropriate
				  reporting and tracking of case adjustments and reopenings;
(5) Other relevant areas selected by the
				  Board.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 440 - MAINE WORKERS' COMPENSATION RESIDUAL MECHANISM › Subchapter IV - SERVICING CARRIER PERFORMANCE STANDARDS › Section 031-440-IV-6 - Board Review

Current through 2024-29, July 17, 2024
The Board of Governors shall from time to time review the
					 servicing carrier performance standards and recommend to the Superintendent
					 such changes as are appropriate to ensure a high quality service and to ensure
					 solvency of the Pool.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 450 - WORKERS' COMPENSATION INSURANCE - EXPERIENCE RATING › Section 031-450-1 - Authority and Purpose

Current through 2024-29, July 17, 2024
This Rule is adopted by the Superintendent pursuant to
				   24-AM.R.S.A.
				  §§212,
				  2303,
				  2382, and
				  2382-D,
				  to provide employers with adequate information regarding their experience
				  modification factors and an opportunity to correct errors, to exclude
				  aggravations of prior work-related injuries from the subsequent employer's
				  experience modification as required by Maine law, and to establish uniform
				  requirements respecting the applicability of experience modification factors to
				  employers that have had a change in ownership, management, control, or
				  operation.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 450 - WORKERS' COMPENSATION INSURANCE - EXPERIENCE RATING › Section 031-450-2 - Scope

Current through 2024-29, July 17, 2024
This Rule is applicable to all intrastate experience
				  modification factors calculated for Maine employers and to the portion of
				  interstate experience modification factors covering exposure in this State.
				  However, the Superintendent may authorize the members of a group self-insurer
				  to adopt rating or assessment mechanisms that modify the application of this
				  Rule to the group's internal operations for the purpose of equitably allocating
				  claim and expense costs, if the Superintendent finds that the rating or
				  assessment mechanism is not contrary to applicable statutory requirements and
				  does not frustrate the purposes of this Rule.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 450 - WORKERS' COMPENSATION INSURANCE - EXPERIENCE RATING › Section 031-450-3 - Effective Date of Experience Modification Factor

Current through 2024-29, July 17, 2024
A.
Experience modification increase; policy effective date.
An
				insurer shall not implement an increase in the experience modification factor
				after the effective date of the policy unless the policy (including any
				applicable endorsements) clearly specifies the terms under which the employer's
				experience rating may be subject to change.
B.
Limitation.
An insurer
				shall not implement an increase in the experience modification factor more than
				90 days after the policy effective date. An insurer or advisory organization
				may appeal to the Superintendent for an extension of the 90-day limitation
				period if there are unusual circumstances which legitimately delay the
				availability of the experience modification factor. This Subsection does not
				apply to the periodic recalculation of the policyholder's experience
				modification factor, in accordance with the terms of the approved experience
				rating plan, if the policyholder has been notified in writing at or before the
				time the policy is issued or renewed that the effective date of the experience
				modification factor is different from the effective date of the
				policy.
C.
Modification
				resulting in premium reduction.
Any change in the experience
				modification factor that results in a premium reduction shall not be subject to
				the restrictions in Subsections A and B above, and shall apply retroactively to
				the entire policy period to the extent affected by the erroneous experience
				modification factor.
D.
Lack of employer cooperation.
The restrictions in Subsections A and B
				above shall not apply if the designated advisory organization is unable to
				calculate the modification factor for an employer solely because the employer
				has failed to cooperate in an audit affecting the modification calculation or
				solely due to the fault of the employer or an agent of the employer.
E.
Changes in rating basis.
This Section does not apply to changes in experience modification factors
				resulting from a change in the governing classification of a business or from a
				change in ownership or other transaction subject to Section7.
Code of Maine Rules › 02 - DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION › 031 - BUREAU OF INSURANCE › Chapter 450 - WORKERS' COMPENSATION INSURANCE - EXPERIENCE RATING › Section 031-450-4 - Information Available to Employers

Current through 2024-29, July 17, 2024
A.
Information available.
At the written request of an employer, the
				insurer or designated advisory organization shall provide within 30 days after
				receipt of the request a copy of the experience rating calculation, including a
				listing of the claims used in determining the experience modification factor.
				Claims with paid or incurred values below the designated advisory
				organization's
de minimis
threshold may be listed in the
				aggregate. The threshold may not exceed $2000 without the prior approval of the
				Superintendent.
B.
Failure
				to comply; prohibition.
If the insurer or designated advisory
				organization fails to provide the requested calculation within 30 days after
				receipt of therequest, then the insurer is prohibited from applying an
				experience modification factor greater than 1.00 for the period between the
				termination of the 30-day response period and the date the requested
				information is received by theemployer.