Ohio Administrative Code › Title 3901 - Department of Insurance › Chapter 3901-1 - General Provisions › Section 3901-1-54 - Unfair property/casualty claims settlement practices

Current through all regulations passed and filed through July 1, 2024
(A) Purpose
The purpose of this rule is to set forth uniform minimum
				standards for the investigation and disposition of property and casualty claims
				arising under insurance contracts or certificates issued to residents of Ohio.
				It is not intended to cover claims involving workers' compensation, or
				fidelity, suretyship, and boiler and machinery insurance. The provisions of
				this rule are intended to define procedures and practices which constitute
				unfair claims practices. Nothing in this rule shall be construed to create or
				imply a private cause of action for violation of this rule.
(B) Authority
This rule is promulgated pursuant to the authority vested in
				the superintendent under sections
				3901.041
				and
				3901.19
				to
				3901.26
				of the Revised Code.
(C)
			 Definitions
As used in this rule:
(1) "Agent" means any individual,
			 corporation, association, partnership or other legal entity authorized to
			 represent an insurer with respect to a claim.
(2) "Claim file" means any retrievable
			 electronic file, paper file, combination of both, or any other media.
(3) "Claimant" means a first party claimant,
			 a third party claimant.
(4)
			 "Contract" means any insurance policy or document containing the terms of the
			 agreement wherein one party, the insurer, assumes certain obligations including
			 financial obligations that arise as a result of a loss sustained by another
			 party, the insured, or to any other party that has rights under the
			 agreement.
(5) "Days" means
			 calendar days. However, when the last day of a time limit stated in this rule
			 falls on a Saturday, Sunday, or holiday, the time limit is extended to the next
			 immediate following day that is not a Saturday, Sunday, or holiday.
(6) "Department" means the Ohio department of
			 insurance.
(7) "Documentation"
			 includes, but is not limited to, all communications, transactions, notes, work
			 papers, claim forms, bills and explanation of benefits forms pertaining to the
			 claim.
(8) "First party claimant"
			 means any individual, corporation, association, partnership or other legal
			 entity asserting a right to payment under an insurance policy or insurance
			 contract arising out of the occurrence of the contingency or loss covered by
			 the policy or contract.
(9)
			 "Insurer" shall be defined as set forth in division 
									(F) of section
			 3901.32
			 of the Revised Code.
(10)
			 "Investigation" means all activities of an insurer directly or indirectly
			 related to the determination of liability under an insurance contract which is
			 in effect or alleged to be in effect.
(11) "Like kind and quality part" means a
			 salvage motor vehicle part equal to or better than the replaced part that is
			 acquired from a licensed salvage motor dealer.
(12) "Notification of claim" means any
			 notification, under the terms of an insurance contract, to an insurer or its
			 agent, by a claimant, which reasonably apprises the insurer of the facts
			 pertinent to a claim.
(13) "Person"
			 shall be defined as set forth in section
			 3901.19
			 of the Revised Code.
(14)
			 "Practice" means a type of activity or conduct engaged in by an insurer with
			 such frequency as to constitute a customary procedure or policy routinely
			 followed in the settlement of insurance claims. A single act is not a business
			 practice. However, an act that is malicious, deliberate, conscious and knowing
			 may be the basis for corrective action ordered only by the superintendent
			 without a showing that the conduct is a practice.
(15) "Superintendent" means the
			 superintendent of insurance.
(16)
			 "Third party claimant" means any individual, corporation, association,
			 partnership or other legal entity asserting a claim against any other
			 individual, corporation, association, partnership or legal entity.
(17) "Proof of loss" means a document from
			 the claimant that provides sufficient information from which the insurer can
			 determine the existence and the amount of the claim.