New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 16 - FRAUD PREVENTION AND DETECTION › Subchapter 6 - FRAUD PREVENTION AND DETECTION PLANS › Section 11:16-6.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, as used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.
"Anti-fraud prevention and detection plan" means the creation and maintenance of an anti-fraud protection and detection protocol, an anti-fraud prevention and detection training program, and an anti-fraud prevention and detection procedure manual.
"Anti-fraud prevention and detection procedure manual" is the collection of New Jersey statutes, New Jersey administrative rules, Federal laws, and company guidelines, policies, and procedures that are distributed to and/or made available to personnel of the insurer in the Special Investigation Unit, and the underwriting and claims, or other applicable processing units of the insurer who are responsible for anti-fraud prevention and detection.
"Anti-fraud prevention and detection protocol" means the document that defines the insurer's compliance with the activities set forth in 11:16-6.3, 6.4, 6.6, and 6.7.
"Anti-fraud prevention and detection training program" means the document which defines the insurer's compliance with the requirements set forth in 11:16-6.5(a).
"Application" means any document that is used in any way by the insurer to rate or underwrite a policy, including the coverage selection form and renewal questionnaire as provided at 11:3-15.7 and 11:3-8 and, if requested, a copy of the applicant's driver's license, a copy of the motor vehicle registration of the principal vehicle to be insured and any additional proof of New Jersey residency.
The term "application" shall also mean those signed forms, data, reports, analysis and other documents supplied in support of an application when requested by an insurer or by any other person, and/or supplied by the insured/applicant, or other person(s), seeking coverage under a policy or plan of health insurance that is provided to or used by an insurer in assessing the risk, or premium, or which is relied upon by the insurer in agreeing to provide coverage under the policy or plan, including but not limited to that information submitted in accordance with 11:4-16.7, 11:20-4.1 and 11:21-6.1.
"Attorney General" means the Attorney General of New Jersey or his or her designated representatives.
"Automobile" means a private passenger automobile of a private passenger or station wagon type that is owned or hired and is neither used as a public or livery conveyance for passengers nor rented to others with a driver; and a motor vehicle with a pickup body, a delivery sedan, a van, or a panel truck or a camper-type vehicle used for recreational purposes owned by an individual or by husband and wife who are residents of the same household, not customarily used in the occupation, profession, or business of the insured other than farming or ranching. An automobile owned by a farm family co-partnership or corporation, which is principally garaged on a farm or ranch and otherwise meets the definitions contained in this section, shall be considered a private passenger automobile owned by two or more relatives resident in the same household.
"Automobile insurance" means direct insurance against injury or damage including the legal liability therefor, arising out of the ownership, operation, maintenance, or use of automobiles, including, but not limited to, personal injury protection insurance, bodily injury liability insurance, property damage liability insurance, physical damage insurance, and uninsured and underinsured motorist insurance.
"Bureau" or "BFD" means the Bureau of Fraud Deterrence established by section 8 of P.L. 2010, c. 32 (17:33A-8 ).
"CAIP" means the Commercial Automobile Insurance Plan as set forth in N.J.A.C. 11:3.
"Commercial lines insurance coverage" means property and liability insurance coverage for commercial motor vehicles as defined in this section.
"Commercial motor vehicle" includes every type of motor-driven vehicle used for commercial purposes on the highways, such as the transportation of goods, wares, and merchandise, excepting such vehicles as are run only upon rails or tracks and vehicles of the passenger car type used for touring purposes or the carrying of farm precuts and milk, as the case may be.
"Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance.
"Department" means the New Jersey Department of Banking and Insurance.
"Eligible person" means an individual who meets the qualifications set forth in N.J.A.C. 11:3-34.
"Exportable List" means the list of certain classes of insurance coverages or risks promulgated by the Commissioner at N.J.A.C. 11:1-34 pursuant to N.J.S.A. 17:22-6.4 3.
"Fraud and misrepresentation" means the knowing misrepresentation of any material fact in a claim or application or the knowing failure to disclose any material fact in a claim or application which, if properly revealed or disclosed, could change the premium, or affect the placement or underwriting of the risk, or the assignment in the insurer's rating plan, or could affect the payment of a claim.
"Fraud prevention and detection plan" or "plan" means an insurer's plan for the prevention and detection of fraudulent insurance applications and claims.
"Health insurance" means a contract or agreement whereby an insurer is obligated to pay or allow a benefit of pecuniary value with respect to the bodily injury, disablement, sickness, death by accident or accidental means of a human being, or because of any expense relating thereto, or because of any expense incurred in prevention of sickness, and includes every risk pertaining to any of the enumerated risks. Health insurance does not include any administrative services only (ASO) contracts, workers' compensation coverage, or stop-loss coverage.
"Health insurance comprehensive benefits" means preventive care, emergency care, inpatient and outpatient provider care, diagnostic laboratory and diagnostic and therapeutic radiological services, and other services as set forth in N.J.A.C. 11:24-5.
"Hospital" means any general hospital, mental hospital, convalescent home, nursing home, or any other institution, whether operated for profit or not, which maintains or operates facilities for health care.
"Insured lives" means the actual number of New Jersey residents entitled to receive benefits under a contract delivered or issued for delivery in this State.
"Insurance company" means:
1. Any corporation, association, partnership, reciprocal exchange, interinsurer, Lloyd's insurer, fraternal benefit society, or other person engaged in the business of insurance pursuant to Title 17 of the Revised Statutes (17:17-1 et seq.), or of Title 17B of the New Jersey Statutes (17B:17-1 et seq.);
2. Any medical service corporation operating pursuant to P.L. 1940, c. 74 (17:48A-1 et seq.);
3. Any hospital service corporation operating pursuant to P.L. 1938, c. 366 (17:48-1 et seq.);
4. Any health service corporation operating pursuant to P.L. 1985, c. 236 (17:48E-1 et seq.);
5. Any dental service corporation operating pursuant to P.L. 1968, c. 305 (17:48C-1 et seq.);
6. Any dental plan organization operating pursuant to P.L. 1979, c. 478 (17:48D-1 et seq.);
7. Any insurance plan operating pursuant to P.L. 1970, c. 215 (17:29D-1 et seq.);
8. The New Jersey Insurance Underwriting Association operating pursuant to P.L. 1968, c. 129 (17:37A-1 et seq.); and
9. Any risk retention group or purchasing group operating pursuant to the Liability Risk Retention Act of 1986, 15 U.S.C. §§
										3901 et seq.
"Insurer" means any person or entity authorized to transact the business of private passenger automobile insurance in New Jersey, whether in accordance with a personal lines or commercial lines rating system, and includes a group of affiliated companies, and the Property Liability Insurance Guaranty Association established pursuant to 17:30A-1 et seq. when performing its statutory function.
"Insurer" pursuant to 17:33A-3 (health insurance) also means:
1. Any corporation, association, partnership, reciprocal exchange, interinsurer, Lloyd's insurer, fraternal benefit society or other person engaged in the business of insurance pursuant to 17:17-1 et seq. or 17B:17-1 et seq.)
2. Any medical service corporation operating pursuant to 17:48A-1 et seq.
3. Any hospital service corporation operating pursuant to 17:48-1 et seq.;
4. Any health service corporation operating pursuant to 17:48E-1 et seq.;
5. Any dental service corporation operating pursuant to 17:48C-1 et seq.
6. Any dental plan organization operating pursuant to 17:48D-1 et seq.
"Limited health care services" means limited benefits policies or contracts such as accident only; accidental death and dismemberment, credit life and disability; long-term care; medicare supplement; dental only; vision only; supplemental liability; and any other supplemental hospital indemnity benefits.
"MCEAFC" means the Market Conduct Examinations and Anti-Fraud Compliance Unit in the Department of Banking and Insurance, Office of Consumer Protection Services.
"OIFP" means the Office of the Insurance Fraud Prosecutor in the Division of Criminal Justice in the Department of Law and Public Safety.
"PAIP" means the New Jersey Personal Automobile Insurance Plan as set forth in N.J.A.C. 11:3-2.
"Pattern" means five or more related violations of P.L. 1983, c. 320 (17:33A-1 et seq.).
"Person" means a person as defined in 1:1-2, and shall include, unless the context otherwise requires, a practitioner.
"Practitioner" means a licensee of this State authorized to practice medicine, surgery, psychology, chiropractic, or law or any other licensee of this State whose services are compensated, directly or indirectly, by insurance proceeds or a licensee similarly licensed in other states or nations or the practitioner of any non-medial treatment rendered in accordance with a recognized religious method of healing.
"Principal residence" means that residence at which a person spends the majority of his or her time. Principal residence may be an abode separate and distinct from a person's domicile. Mere seasonal or weekend residence within this State does not constitute principal residence within this State.
"Private passenger automobile insurance" means a policy of automobile insurance principally used to provide primary insurance on private passenger automobiles that are owned individually or jointly by individuals who are residents of the same household, and used for personal, family, or household needs.
"Producer" means an insurance producer as defined in section 3 of P.L. 2001, c. 210 (17:22A-28 ), licensed to transact the business of insurance in this State pursuant to the provisions of the New Jersey Insurance Producer Licensing Act of 2001, 17:22A-26 et seq.
"Special Investigations Unit" or "SIU" means the functional group established by an insurer to carry out the duties set forth in 11:16-6.4.
"Statement" includes, but is not limited to, any application, writing, notice, expression, statement, proof of loss, bill of lading, receipt, invoice, account, estimate of property damage, bill for services, diagnosis, prescription, hospital or physician record, X-ray, test result, or other evidence of loss, injury, or expense.
"Stop-loss or excess risk insurance" means insurance designed to reimburse a self-funded arrangement for catastrophic and unexpected expenses exceeding specified person retention limits and/or aggregate retention limits, wherein neither the employees nor other individuals are third party beneficiaries under the policy, contract or plan.