reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 24C - MANAGED CARE PLANS › Subchapter 4 - PROVIDER NETWORKS › Section 11:24C-4.6 - Standards for accuracy of provider directory information

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Carriers shall implement a system for maintaining accurate and current information on all providers listed in a network directory.
(b) Carriers shall ensure the information in the provider directory is based on the most recently submitted information from the provider or the Council for Affordable Quality Healthcare (CAQH).
(c) Carriers shall update electronic directories within 20 days of the carrier's receipt of confirmation from a provider or CAQH that current information is inaccurate or has changed. When a carrier disputes a notice that information on a provider is inaccurate, the carrier shall, within 15 days of receipt of a notice from a provider or consumer asserting that the information is inaccurate, respond to the notice in writing and include in its response the reason(s) supporting its position that the challenged information is accurate.
(d) Carriers shall confirm the participation of any provider who has not submitted a claim for a period of 12 months or otherwise communicated with the carrier in a manner evidencing the provider's intention to continue to participate in the carrier's network and for whom no change in provider status has been reported by CAQH. The process for confirming participation shall be as follows:
1. The carrier shall contact the provider and request that the provider confirm his or her intention to continue to participate in the carrier's provider network. Based on the provider's response, the carrier shall update its directories as necessary.
2. If the provider fails to respond to a communication by the carrier, the carrier shall mail a follow-up request to the provider by certified mail, return receipt requested. If the provider fails to respond to such request within 30 days, the carrier shall remove the provider from its network and update its directories as necessary.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 25 - OFFICE OF THE INSURANCE CLAIMS OMBUDSMAN › Subchapter 1 - GENERAL POWERS AND DUTIES › Section 11:25-1.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to establish procedures for the Insurance Claims Ombudsman to exercise his or her statutory authority to:
1. Investigate consumer complaints involving policies of insurance, including the payment of claims;
2. Monitor the implementation of 17:23A-1 et seq. (policyholder's personal information disclosure practices of regulated insurers);
3. Monitor the implementation of 17:29B-1 et seq. and 17B:30-1 et seq. (consumer complaints regarding unfair methods of competition; unfair, deceptive and discriminatory acts or practices by insurers);
4. Monitor the implementation of 17:35C-1 et seq. (Medicare supplement health insurance policies; regulation of contract provisions and required disclosure to consumers);
5. Investigate alleged violations of 17:35C-11 (use of false, misleading, or fraudulent statements and advertising to sell Medicare supplement insurance to consumers);
6. Respond to consumer inquiries, including, but not limited to, those regarding policy terms and availability of coverage;
7. Ensure that accurate and understandable buyers' guides and rate comparisons are published and disseminated to consumers where required by law, except those with respect to health insurance coverages provided pursuant to 17B:27A-2 et seq. and 17B:27A-17 et seq.;
8. Review the conduct of arbitrators appointed in accordance with the terms of a policy of insurance to arbitrate disputes, except those arbitration proceedings arising out of policies issued pursuant to 39:6A-1 et seq. or already subject to the provisions of N.J.A.C. 11:22-1;
9. Investigate such other improper patterns or practices as are deemed necessary and appropriate to the Office of Insurance Claims Ombudsman; and
10. Review disputes that are appealed by consumers after an internal appeals procedure (N.J.A.C. 11:25-2 ) is conducted by life, property and casualty insurers.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 25 - OFFICE OF THE INSURANCE CLAIMS OMBUDSMAN › Subchapter 1 - GENERAL POWERS AND DUTIES › Section 11:25-1.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise:
"Claim" means any claim filed under a policy of insurance issued pursuant to 17:17-1 et seq., 39:6A-1 et seq., or any policy of life or health insurance issued pursuant to Title 17 or Title 17B of the New Jersey Statutes.
"Commissioner" means the Commissioner of the Department of Banking and Insurance.
"Consumer complaint" means any inquiry filed with the Department or the Ombudsman under a policy of insurance issued pursuant to 17:17-1 et seq., 39:6A-1 et seq., or any policy of life or health insurance issued pursuant to Title 17 or Title 17B of the New Jersey Statutes.
"Disputed insurance claim" means any offer of settlement made by any insurer which is, in whole or in part, rejected or refused by the claimant or a claim denial.
"Insurance" means any contract of direct insurance written pursuant to 17:17-1 et seq., 39:6A-1 et seq., or any policy of life or health insurance issued pursuant to Title 17 or Title 17B of the New Jersey Statutes.
"Insured" means any individual, policyholder, or entity who has purchased a policy of direct insurance written pursuant to 17:17-1 et seq., 39:6A-1 et seq., or any policy of life or health insurance issued pursuant to Title 17 or Title 17B of the New Jersey Statutes.
"Insurer" means any entity authorized or admitted to transact the business of a property/casualty or life or health insurance in accordance with Titles 17 and 17B of the New Jersey Statutes.
"Ombudsman" or "Insurance Claims Ombudsman" means the Office of Insurance Claims Ombudsman within the New Jersey Department of Banking and Insurance established in accordance with 17:29E-1.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 25 - OFFICE OF THE INSURANCE CLAIMS OMBUDSMAN › Subchapter 1 - GENERAL POWERS AND DUTIES › Section 11:25-1.3 - General provisions; disputed claims

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Upon the request of a consumer, the Ombudsman may conduct a review of any disputed insurance claim settlement where there is reasonable cause to believe that an insurer has failed or refused to settle a claim in accordance with the provisions of the policy or has engaged in any practice that may constitute a violation of 17:23A-1 et seq., 17:29B-1 et seq., 17:35C-1 et seq., 17B:30-1 et seq., or 17:35C-11; or
(b) Consumers seeking review in accordance with (a) above shall file a complaint with the Ombudsman in any form, which indicates that the complainant is seeking review of a disputed claim. All complaints shall be sent to:
New Jersey Department of Banking and Insurance
Consumer Assistance
20 West State Street
PO Box 329
Trenton, NJ 08625-0329
Telephone: (609) 292-7272
Telefax: (609) 292-2431 or (609) 777-0508
Automated Hotline: 1-800-446-7467
E-mail: ombudsman@dobi.nj.gov
Electronic complaint submissions:
http://www.state.nj.us/dobi/consumer.htm
1. All complaints received by the Ombudsman shall be entered into the data tracking system of the Consumer Assistance Unit in the Office of Consumer Protection Services. The Ombudsman shall retain complaints for further action, or refer them to the Consumer Assistance Unit in the Office of Consumer Protection Services for disposition. The Consumer Assistance Unit in the Office of Consumer Protection Services may likewise refer matters to the Ombudsman.
2. If the Ombudsman needs further information on any complaint, the office shall notify the complainant of the additional information needed before any further action may be taken.
3. A copy of the filed complaint shall be sent promptly to the respondent together with a transmittal letter that advises the respondent that an answer to the complaint must be filed no more than 15 business days after the date of receipt of the transmittal letter.
4. The respondent may raise a general denial to the complainant's allegations and may also raise such other legal, contractual or equitable defenses, which explain or justify the actions of the respondent.
5. Thereafter, the complainant shall be advised of the respondent's contentions and given an opportunity to rebut within 15 business days of receipt of the notice.
6. When deemed appropriate, the Ombudsman may extend all time limits mentioned in this subsection.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 25 - OFFICE OF THE INSURANCE CLAIMS OMBUDSMAN › Subchapter 1 - GENERAL POWERS AND DUTIES › Section 11:25-1.4 - Consultants and experts

Current through Register Vol. 56, No. 14, July 15, 2024
When deemed necessary to any inquiry undertaken pursuant to this subchapter, the Ombudsman may, in accordance with N.J.S.A. 17:29E-3b, engage the services of consultants and other professionals to assist in the investigation or understanding of any relevant issue, pursuant to all applicable laws regarding same.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 25 - OFFICE OF THE INSURANCE CLAIMS OMBUDSMAN › Subchapter 1 - GENERAL POWERS AND DUTIES › Section 11:25-1.5 - Trade and marketing practices; investigations, hearings and complaints

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Ombudsman may, upon his or her initiative, or upon the filing of a complaint by any interested party, conduct an investigation and/or hearing into an insurer's trade practices, including claims settlement practices, and marketing practices which may deviate from 17:29B-1 et seq., 17B:30-1 et seq., and/or N.J.A.C. 11:2-17.
(b) When making investigations or conducting hearings, the Ombudsman may consider any and all information deemed necessary and proper to resolve the issues raised by the investigation or hearing.
(c) The Ombudsman may inspect and copy books, papers, objects, documents, records and other evidence considered material or relevant to the matter under investigation, and may issue a subpoena to compel any person to attend and testify as well as to produce documents, books, papers, objects, records and other evidence at such place and time as is selected by the Ombudsman.
(d) At the conclusion of the investigation, inquiry or hearing, the Ombudsman may, in his or her discretion or at the request of the Commissioner, issue a report as to any findings and conclusions reached regarding the trade practice, marketing practice, policy or provision being investigated. The Ombudsman may determine if any policy provision, endorsement or form is unfairly discriminatory, confusing, misleading or contrary to public policy together with a specific recommendation as to the modification or discontinuance of the policy, form or provision. The report may also include a recommendation to the Commissioner regarding any further investigation of an insurer's practices together with a recommendation regarding the imposition of penalties or other sanctions.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 25 - OFFICE OF THE INSURANCE CLAIMS OMBUDSMAN › Subchapter 1 - GENERAL POWERS AND DUTIES › Section 11:25-1.6 - Registry of closed complaints and confidentiality of information

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Ombudsman shall maintain a central registry of all closed complaint investigations that shall contain information on the nature of the investigation, findings and disposition. The Ombudsman shall report to the Commissioner any evidence that an insurer may be engaged in a pattern of conduct which violates 17:29B-1 et seq., 17:23A-1 et seq., 17:29B-1 et seq., 17B:30-1 et seq., 17:35C-1 et seq., or 17:35C-11. The contents of this central registry shall be confidential and shall not be subject to public inspection or copying pursuant to the "Right to Know Law," 47:1A-1 et seq.
(b) Any correspondence or written communication from any complainant and any written material submitted by an insurer to the Ombudsman shall remain confidential and shall not be considered a public record pursuant to the "Right to Know Law," 47:1A-1 et seq., and shall not be subject to release unless such disclosure is necessary to enable the Ombudsman to perform his or her duties and to support any opinions or recommendations, or as may be necessary to enable the Commissioner to perform any function authorized by law, including any action to stop unfair claims settlement practices. Any statement or communication made by the Ombudsman or which is provided in good faith to the Ombudsman shall be deemed to be privileged and confidential in accordance with 17:29E-12.c. Confidentiality shall attach only after the Ombudsman has exercised his or her jurisdiction to investigate a complaint. Complaints sent to the Ombudsman that he or she does not elect to investigate pursuant to 11:25-1.4(c)2  shall be returned to the complainant or referred to the Consumer Assistance Unit in the Office of Consumer Protection Services for further action. Only those complaints retained by the Ombudsman shall be subject to the confidentiality provision of this chapter.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 25 - OFFICE OF THE INSURANCE CLAIMS OMBUDSMAN › Subchapter 1 - GENERAL POWERS AND DUTIES › Section 11:25-1.7 - Publication of information

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every buyer's guide given to insureds in accordance with Title 11 of the New Jersey Administrative Code shall contain a notice describing the existence and function of the Office of Insurance Claims Ombudsman together with the mailing address, toll-free telephone number and e-mail address listed below.
(b) As a part of any claim, claim denial, payment, compromise or any other disposition, all insurers shall provide notice and explanation of the insurer's internal appeal process that is established in accordance with N.J.A.C. 11:25-2.
(c) As a part of any final action taken by an insurer's internal appeals panel, except those covered by 39:6A-5.1 and 5.2 and N.J.A.C. 11:22-1, notice shall be provided to all parties that the Office of Insurance Claims Ombudsman may be contacted at the address in (d) below if further review is sought.
(d) Any document described at (a), (b), and (c) above shall list the following information for contacting the Ombudsman:
New Jersey Department of Banking and Insurance
Consumer Assistance
20 West State Street
PO Box 329
Trenton, NJ 08625-0329
Telephone: (609) 292-7272
Telefax: (609) 292-2431 or (609) 777-0508
Automated Hotline: 1-800-446-7467
E-mail: ombudsman@dobi.nj.gov
Electronic complaint submissions:
http://www.state.nj.us/dobi/consumer.htm
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 25 - OFFICE OF THE INSURANCE CLAIMS OMBUDSMAN › Subchapter 2 - INTERNAL APPEALS PROCEDURE › Section 11:25-2.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to implement the provisions of 17:29E-9, that requires life, property and casualty insurers to establish an internal appeals procedure for consumers seeking review of disputed claims.
(b) This subchapter shall apply to all disputed consumer claims with the exception of those to which the provisions of 39:6A-5.1 and 5.2 apply (that is, disputes arising out of personal injury protection coverage claims) or the process established in N.J.A.C. 11:22-1.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 25 - OFFICE OF THE INSURANCE CLAIMS OMBUDSMAN › Subchapter 2 - INTERNAL APPEALS PROCEDURE › Section 11:25-2.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.
"Claim" means any claim filed under a policy of insurance issued pursuant to 17:17-1 et seq., 39:6A-1 et seq., or any policy of life insurance issued pursuant to Title 17 or Title 17B of the New Jersey Statutes.
"Claimant" means a first-party claimant, a third-party claimant, or a designated representative.
"Claims settlement" means all activities of an insurer relating directly or indirectly to the determination of the extent of liabilities due or potentially due under the coverage afforded by the policy, and which can or does result in a claim payment or acceptance, compromise or rejection.
"Insured" means any individual, policyholder, or entity who has purchased a policy of property and casualty insurance or any policy of life insurance issued pursuant to Title 17 or Title 17B of the New Jersey Statutes.
"Insurer" means any entity authorized or admitted to transact the business of a property/casualty and life insurance in accordance with Titles 17 and 17B of the New Jersey Statutes.
"Internal appeals" means any notification, in written form which is received either by mail, electronic mail, facsimile or by delivery to the insurer that advises the insurer that the final offered claim settlement remains unacceptable to the claimant.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 25 - OFFICE OF THE INSURANCE CLAIMS OMBUDSMAN › Subchapter 2 - INTERNAL APPEALS PROCEDURE › Section 11:25-2.3 - Complaint and internal appeals system-general requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every insurer shall establish and maintain an internal appeals system to provide for the presentation and review of complaints brought by a consumer. All internal appeals procedures shall, at a minimum, include the following components:
1. A system to record and document the status of all internal appeals including whether the appeal is pending or resolved, the type of coverage, type of claim, the specific disposition of the appeal, and the amount of additional benefits paid on resolved internal appeals. The data shall be maintained for a period of three years from the date the internal appeal is closed and shall be made available to the Department upon request;
2. The availability of an insurer's member service representative to assist insureds, when requested, with information pertaining to the insurer's internal appeals system;
3. Establishment of a specified response time which shall be no more than 10 business days from receipt of the appeal for disposition of an internal appeal;
4. A communication sent to the claimant when the appeal is filed which describes in non-technical terms how internal appeals are processed and resolved;
5. Procedures for follow-up action including methods to inform the complainant of the decision of the internal appeals panel within three working days of its decision; and
6. A mechanism for notifying claimants in writing that they may contact the Insurance Claims Ombudsman if there continues to be dissatisfaction with the decision reached by the insurer's internal appeals panel.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 25 - OFFICE OF THE INSURANCE CLAIMS OMBUDSMAN › Subchapter 2 - INTERNAL APPEALS PROCEDURE › Section 11:25-2.4 - Composition of internal appeals panel

Current through Register Vol. 56, No. 14, July 15, 2024
The internal appeals review shall be conducted by a panel of at least three of the insurer's employees who possess experience and expertise in claims procedures but are not assigned to day-to-day claims payment and adjustment.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 25 - OFFICE OF THE INSURANCE CLAIMS OMBUDSMAN › Subchapter 2 - INTERNAL APPEALS PROCEDURE › Section 11:25-2.5 - Notice to insureds and maintenance of data

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All insurers shall provide policyholders and claimants with a written explanation of the insurer's internal appeals system which is consistent with this subchapter, including any pertinent telephone numbers, fax numbers, e-mail addresses (if used) and business addresses to which the internal appeals shall be submitted.
(b) The insurer shall maintain continuously updated records regarding all internal appeals processed in accordance with this subchapter and shall make the data available, upon request, to the Department or to the Office of the Insurance Claims Ombudsman. The data shall include, but not be limited to:
1. A copy of the internal appeal filed by the insured;
2. A copy of the decision being appealed;
3. A list of the documents, records and other pertinent information relied upon by an internal appeals panel in deciding the appeal; and
4. A copy of the notice sent to the claimant advising the claimant of the decision and the right to subsequent appeals in accordance with 11:25-2.3.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 25 - OFFICE OF THE INSURANCE CLAIMS OMBUDSMAN › Subchapter 2 - INTERNAL APPEALS PROCEDURE › Section 11:25-2.7 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
Failure to comply with the provisions of this subchapter and 11:25-1.7 shall subject the insurer to penalties as provided by 17:29E-14.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 1 - GENERAL PROVISIONS › Section 11:27-1.1 - Purpose

Current through Register Vol. 56, No. 14, July 15, 2024
The purpose of this chapter is to implement the New Jersey Medical Care Access and Responsibility and Patients First Act, P.L. 2004, c. 17 as it applies to insurers authorized to transact medical malpractice liability insurance in this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 1 - GENERAL PROVISIONS › Section 11:27-1.2 - Scope

Current through Register Vol. 56, No. 14, July 15, 2024
This chapter applies to all insurers authorized to transact medical malpractice liability insurance in this State and to the medical malpractice liability insurance policies issued by such authorized insurers, as more specifically set forth in the subchapters that follow.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 1 - GENERAL PROVISIONS › Section 11:27-1.3 - Separability

Current through Register Vol. 56, No. 14, July 15, 2024
If any provision of this chapter or its application to any person or circumstance is held to be invalid, the remainder of this chapter and its application to other persons or circumstances shall not be affected.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 2 - OPTIONAL POLICY PROVISION-RIGHT TO CONSENT TO SETTLEMENT › Section 11:27-2.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to provide an option to insureds covered by medical malpractice insurance policies that contain a "consent by the insured to settle" provision to waive that provision by way of endorsement, and to require insurers to provide a premium reduction reflecting any savings or reduced costs if the endorsement providing for a waiver of the "right to consent to settle" provision is selected.
(b) This subchapter shall apply to any medical malpractice insurance policy made, issued or delivered in this State by an authorized insurer on or after December 4, 2004.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 2 - OPTIONAL POLICY PROVISION-RIGHT TO CONSENT TO SETTLEMENT › Section 11:27-2.2 - Optional policy provision; right to settle

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A medical malpractice liability insurance policy may provide that a person insured under the policy has the exclusive right to require the insurer to obtain the consent of the insured to settle any claim filed against the insured.
(b) If a medical malpractice liability policy made, issued or delivered in this State by an authorized insurer on or after December 4, 2004 contains a provision as described in (a) above, the insurer shall offer an endorsement, to be included in the policy at the option of the insured, providing that the insurer may settle a claim filed under the policy without first having obtained the insured's consent. The insurer shall establish a premium discount for that endorsement, which shall reflect any savings or reduced costs attributable to the endorsement.
1. With respect to new applications for coverage under policies which include a provision as referenced in (a) above, notice of the offering of the endorsement and corresponding premium discount shall be provided on the application form or in an attachment accompanying the application form.
2. If the offering of the endorsement constitutes a change in the contract terms of a policy being renewed, notice thereof and of the corresponding premium discount shall be provided to the insured in accordance with 11:1-20.2(c).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 3 - MANDATORY DEDUCTIBLES › Section 11:27-3.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter sets forth the requirements applicable to deductibles which shall be offered by all authorized medical malpractice liability insurers on medical malpractice liability insurance policies transacted in this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 3 - MANDATORY DEDUCTIBLES › Section 11:27-3.2 - Mandated deductible amounts

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All insurers authorized to transact medical malpractice liability insurance in this State shall include in their offered medical malpractice liability insurance policies a range of at least five deductible amounts applicable to indemnity only, with the selection of the deductible to be at the option of the insured. The offered deductibles shall range from at least $5,000 per claim on all policies regardless of the liability limits and up to $1,000,000 per claim on policies with liability limits of at least $1,000,000/$3,000,000. Any medical malpractice liability insurance policy that contains a provision that includes defense costs within policy limits shall conform to the standards set forth in 11:13-7.3(c).
1. Examples of deductibles which may be included in the range of five deductibles to be offered as set forth above are:
$5,000 per incident, $15,000 annual aggregate deductible
$10,000 per incident, $30,000 annual aggregate deductible
$25,000 per incident, $75,000 annual aggregate deductible
$50,000 per incident, $150,000 annual aggregate deductible
$100,000 per incident, $300,000 annual aggregate deductible
$150,000 per incident, $450,000 annual aggregate deductible
$200,000 per incident, $600,000 annual aggregate deductible
$250,000 per incident, $750,000 annual aggregate deductible
$500,000 per incident, $1.5 Million annual aggregate deductible
$750,000 per incident, $2.25 Million annual aggregate deductible
$1 Million per incident, $3 Million annual aggregate deductible
Intermediate deductible amounts shall be interpolated accordingly.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 3 - MANDATORY DEDUCTIBLES › Section 11:27-3.3 - Premium reduction for deductible

Current through Register Vol. 56, No. 14, July 15, 2024
All authorized medical malpractice insurers shall provide an appropriate premium reduction for any deductible chosen by an insured pursuant to the above section.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 3 - MANDATORY DEDUCTIBLES › Section 11:27-3.4 - Filing requirement

Current through Register Vol. 56, No. 14, July 15, 2024
An insurer authorized to transact medical malpractice liability insurance in this State shall, where required by N.J.S.A. 17:29AA-5 and N.J.A.C. 11:1-2, file a manual rule on the deductible options offered pursuant to 11:27-3.2 and on the corresponding premium credits provided as required by 11:27-3.3.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 3 - MANDATORY DEDUCTIBLES › Section 11:27-3.5 - Collateral for deductible

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All authorized medical malpractice insurers may require insureds to provide collateral for the deductible option chosen by the insured pursuant to 11:27-3.2.
1. Any collateral required shall be in an amount that bears a reasonable relationship to the amount of the deductible to be secured. Acceptable forms of collateral shall include surety bonds, irrevocable letters of credit issued by a bank, and such other forms as are deemed mutually agreeable by the insurer and insured.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 4 - PREMIUM PAYMENT INSTALLMENTS › Section 11:27-4.1 - Minimum standards for optional installment premium payments

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Every insurer authorized to transact medical malpractice liability insurance in this State shall offer its insureds an installment premium payment option on such policies, and shall file manual rules which shall include:
1. A minimum initial deposit required, which shall be no more than 50 percent of the estimated total premium;
2. A schedule for the payment of premiums on an installment basis which shall provide for intervals of at least two months;
3. No interest charges;
4. An installment charge of the lesser of one percent of the total premium or $25.00 per installment; and
5. A payment plan as listed in (b) below; or a payment plan already in existence with terms no less favorable than those in (b) below.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 5 - PROHIBITED PREMIUM INCREASE › Section 11:27-5.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to prohibit increases in premiums for New Jersey medical malpractice insurance policy renewals based upon claims filed against insureds where the insured is dismissed from a civil action based upon that claim at an early stage of the civil proceeding.
(b) This subchapter shall apply to any New Jersey medical malpractice insurance policy renewal issued by an insurer authorized to transact medical malpractice liability insurance in this State.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 5 - PROHIBITED PREMIUM INCREASE › Section 11:27-5.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise.
"Action" means a civil action commenced in a court of any State or a Federal court.
"Responsive pleading" means any pleading other than a complaint recognized by the rules governing a civil action alleging medical malpractice commenced in any state or by the Federal Rules of Civil Procedure, as applicable, wherein statements in the nature of answers or replies to allegations made against the party filing the pleading are contained.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 5 - PROHIBITED PREMIUM INCREASE › Section 11:27-5.3 - Prohibited premium increase

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An insurer authorized to transact medical malpractice liability insurance in this State shall not increase the premium of any medical malpractice liability insurance policy upon the renewal of that policy on the basis of a claim of medical negligence or malpractice against the insured if the insured is dismissed from a lawsuit alleging medical negligence or malpractice based upon that claim, with no indemnity payment by the insurer, prior to or within 180 days after the filing of the last responsive pleading in the action.
(b) In the assignment of the premium of any new business medical malpractice liability insurance policy, an insurer authorized as set forth in (a) above shall not consider a claim of medical negligence or malpractice against the insured if the insured is dismissed from a lawsuit alleging medical negligence or malpractice based upon that claim, with no indemnity payment by the insurer, prior to or within 180 days after the filing of the last responsive pleading in the action.
(c) An insurer authorized as set forth in (a) above which considers, in the assignment of a premium on any medical malpractice liability insurance policy a claim of medical negligence or malpractice against the insured which was pending at the time of the assignment of a premium shall, in the event that a lawsuit based upon that claim is subsequently dismissed as to the insured within 180 days after the filing of the last responsive pleading in the action, with no indemnity payment by the insurer attributable to that claim, upon the renewal next succeeding such a dismissal, reflect the elimination of this claim in the calculation of the renewal premium.
(d) Where required by N.J.S.A. 17:29AA-5 and N.J.A.C. 11:1-2, an insurer authorized to transact medical malpractice liability insurance in this State shall file a manual rule as to this provision with the Department of Banking and Insurance for inclusion in the company's manual.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 6 - RENEWAL AND NONRENEWAL NOTICES › Section 11:27-6.1 - Renewal and nonrenewal notices

Current through Register Vol. 56, No. 14, July 15, 2024
Medical malpractice liability insurers shall comply with N.J.A.C. 11:1-20 with regard to notices of renewal and nonrenewal of medical malpractice liability insurance policies.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 7 - MEDICAL MALPRACTICE LIABILITY INSURANCE PREMIUM ASSISTANCE FUND-PREMIUM SUBSIDY › Section 11:27-7.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The purpose of this subchapter is to set forth procedures for the assessment of certain practitioners and employers for the Fund, and the procedures and methodology for determining eligibility for, making application for, and determining the amount of disbursements from the Fund of medical malpractice liability insurance premium subsidies pursuant to 17:30D-28 through 17:30D-30.
(b) This subchapter shall apply with respect to assessments of certain practitioners and employers for the Fund pursuant to 17:30D-29, and to any person seeking a disbursement from the Fund of a premium subsidy pursuant to 17:30D-28 through 17:30D-30.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 7 - MEDICAL MALPRACTICE LIABILITY INSURANCE PREMIUM ASSISTANCE FUND-PREMIUM SUBSIDY › Section 11:27-7.3 - Assessments of employers and certain practitioners

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In accordance with 17:30D-29, notices imposing an annual charge in the sum of $ 75.00 shall be issued on behalf of the Boards to every physician, podiatrist, chiropractor, dentist and optometrist:
1. Who holds an active license granted on a date one year or more before the date on which the notices are sent;
2. Whose practice is not currently barred or prohibited by statute as unlicensed practice:
i. As a result of the entry of a disciplinary order of the Board revoking or suspending full licensure privileges; or
ii. As a result of the failure to timely renew an expired license, pursuant to 45:1-7.1; and
3. Who is not completely retired from the practice of the profession.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 7 - MEDICAL MALPRACTICE LIABILITY INSURANCE PREMIUM ASSISTANCE FUND-PREMIUM SUBSIDY › Section 11:27-7.4 - Data requests

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department shall request that insurers and other entities providing medical malpractice liability insurance in this State provide the following information with respect to data as of December 31, 2004, 2005 and 2006:
1. The company's base rates (based on $ 1 million/$ 3 million limits). The rates should be provided for each rating tier (for example, preferred, standard, etc.), each policy form (occurrence, claims-made), and by each specialty and subspecialty;
2. The company's in-force exposures, by policy form, by rating tier, and by specialty and subspecialty, for all limits combined;
3. The company's average written premiums, including all factors, surcharges, discounts, etc., per exposure by policy form, by rating tier, by specialty and subspecialty; and
4. Such other data from an insurer or other entity as the Commissioner may conclude is necessary in order to determine the class or classes of specialties or subspecialties which will be eligible for a subsidy and the amount of any qualifying premium and professional liability funding obligation increase or increases as referenced in 11:27-7.5(a) and (b).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 7 - MEDICAL MALPRACTICE LIABILITY INSURANCE PREMIUM ASSISTANCE FUND-PREMIUM SUBSIDY › Section 11:27-7.5 - Determination of eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Commissioner shall determine the class or classes of practitioners eligible for the subsidy, by specialty or subspecialty, for each type of practitioner whose average medical malpractice liability insurance premium, as a class, on or after December 31, 2002, is in excess of an amount determined by the Commissioner based upon a review of the information filed pursuant to 11:27-7.4 and in accordance with 17:30D-30. In determining the relevant premium amounts, the Commissioner shall review and consider, without limitation, the premiums paid or charged by insurers transacting business in this State for medical malpractice liability insurance in this State. In certifying the class or classes of practitioners eligible to receive the subsidy, the Commissioner may, in consultation with the Commissioner of the Department of Health and Senior Services, also consider whether access to care is threatened by the inability of a significant number of practitioners in a particular specialty or subspecialty to continue practicing in a geographic area of the State.
(b) Practitioners in a class certified by the Commissioner in accordance with (a) above, including those whose medical malpractice liability insurance coverage is supplied by health care providers who provide professional liability insurance through self-insured hospital funding supplemented with purchased commercial insurance coverage, shall be eligible for a subsidy if:
1. The practitioner received an increase in medical malpractice liability insurance premiums in excess of an amount determined by the Commissioner based on a review of the information filed pursuant to 11:27-7.4 for one or more of the following: upon policy inception or renewal on or after January 1, 2004, January 1, 2005, and January 1, 2006, from the amount paid in the immediately preceding calendar year(s); or
2. In the case of practitioners whose medical malpractice liability coverage is supplied by health care providers in the manner set forth in (b) above, the Commissioner determines that the health care provider increased its total professional liability funding obligation in excess of an amount determined by the Commissioner based on a review of the information filed pursuant to 11:27-7.4 for one or more of the three year periods set forth in (b)1 above.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 7 - MEDICAL MALPRACTICE LIABILITY INSURANCE PREMIUM ASSISTANCE FUND-PREMIUM SUBSIDY › Section 11:27-7.6 - Application process

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Practitioners and healthcare providers deemed eligible to apply for a subsidy from the Fund as provided in 11:27-7.5 shall file an application in a form to be prescribed by the Department and posted on the Department's website at
www.njdobi.org
. The information provided in the application shall include, but not be limited to, the following:
1. Applicant's name, address, daytime telephone number and business address;
2. Applicant's e-mail address;
3. Applicant's type of licensure and license number;
4. Information related to the type of practice; and
5. Information related to the applicant's medical malpractice liability insurer, including insurer name, policy dates and limits of liability.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 7 - MEDICAL MALPRACTICE LIABILITY INSURANCE PREMIUM ASSISTANCE FUND-PREMIUM SUBSIDY › Section 11:27-7.7 - Distribution of funds

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When distributed based upon a determination of eligibility as set forth in 11:27-7.5(a) and (b), the amount of the subsidy to be distributed for a relevant period shall be in the proportion that the qualifying increases in premiums and funding obligations for all eligible classes relate to the total amount of monies collected and allocated for distribution pursuant to N.J.S.A. 17:30D-29e(1), less administrative costs incurred in administering the Fund. Where eligibility for the subsidy is based on a determination that access to care is threatened in accordance with 11:27-7.5(c), the amount of the subsidy to be distributed for the relevant period shall be in the proportion that the number of qualifying practitioner-applicants in the eligible classes relates to the total amount of monies collected and allocated for distribution pursuant to N.J.S.A. 17:30D-29e(1), less administrative costs incurred in administering the Fund. The Commissioner may adjust the proportional amount of the subsidy distributed to an eligible class based on the average expenditure for medical malpractice liability insurance by practitioners in a class relative to the average expenditure by practitioners in the other eligible classes. The formula utilized to make such an adjustment shall be set forth in the Order issued pursuant to 11:27-7.5(f)2  and applied to the data collected pursuant to 11:27-7.4 for the year to which the subsidy pertains.
(b) Payments pursuant to (a) above shall be disbursed to each eligible applicant or to the applicant's designee as soon as practicable after the termination of the application period as set forth in 11:27-7.6(c).
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 7 - MEDICAL MALPRACTICE LIABILITY INSURANCE PREMIUM ASSISTANCE FUND-PREMIUM SUBSIDY › Section 11:27-7.8 - Practice requirement and penalties

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pursuant to N.J.S.A. 17:30D-30d(1), a practitioner who receives a premium subsidy pursuant to 17:30D-30 shall thereafter be required to continue to practice at least to the same extent (for example, full-time or part-time, and no restriction in specialty or subspecialty) in that practitioner's specialty or subspecialty in this state for a period of at least two years from the issue date of the subsidy. A practitioner may seek a waiver of the two-year practice continuation requirement by filing a certification with the Commissioner that sets forth the reason(s) the practitioner is or will be unable to fulfill the minimum two-year practice requirement. The Commissioner shall grant the waiver of completion of the minimum two-year practice requirement only for the following reasons:
1. Disabled and therefore unable to practice in the specialty or subspecialty prior to the end of the service period;
2. Death;
3. Extended maternity leave beyond the period of disability;
4. Full-time duty with the armed forces, VISTA or the Peace Corps; or
5. Leave taken in accordance with the New Jersey Family Leave Act, 34:11B-1 et seq., or the Family and Medical Leave Act of 1993, 29 U.S.C. §§
											2601 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 8 - OFFICERS, DIRECTORS AND BOARD MEMBERS OF MEDICAL MALPRACTICE INSURERS › Section 11:27-8.1 - Prohibition upon concurrently serving in dual capacity

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No person who is an officer, director or board member of a professional association for health care providers shall serve concurrently as an officer, director or board member of a State-domiciled medical malpractice liability insurer that is licensed in New Jersey and offering medical malpractice liability insurance policies. For the purposes of this section, a professional association shall not include a professional association formed in accordance with 14A:17-1 et seq. and 13:35-6.1 6(f)2.
(b) For the purposes of this section only, a health care provider means an individual or entity which, acting within the scope of its licensure or certification, provides health care services, and includes, but is not limited to, a physician, dentist, nurse or other health care professional whose professional practice is regulated pursuant to Title 45 of the Revised Statutes and a health care facility licensed pursuant to 26:2H-1 et seq.
(c) A person or professional association who violates the provisions of this section and/or 17:30D-18 shall be liable for a civil penalty of $ 10,000 for each violation.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 9 - MEDICAL MALPRACTICE LIABILITY INSURANCE PURCHASING ALLIANCES › Section 11:27-9.1 - Purpose and scope

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This subchapter implements P.L. 2004, c. 17 by establishing rules for the formation and operation of medical malpractice liability insurance purchasing alliances.
(b) This subchapter shall apply to alliances of eligible physicians as defined at 45:9-1 et seq.
New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 27 - MEDICAL MALPRACTICE LIABILITY INSURANCE › Subchapter 9 - MEDICAL MALPRACTICE LIABILITY INSURANCE PURCHASING ALLIANCES › Section 11:27-9.2 - 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:
"Board" means a medical malpractice liability insurance purchasing alliance board of directors as provided for at P.L. 2004, c. 17, §14.
"Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance.
Department" means the New Jersey Department of Banking and Insurance.
"Insurer" means any insurer or insurance association authorized to issue medical malpractice liability insurance in this State.
"Medical malpractice liability insurance purchasing alliance," "purchasing alliance" or "alliance" means a purchasing alliance established pursuant to P.L. 2004, c. 17, §14.
"Member" means a physician or a physician group practice that is a member of a medical malpractice liability insurance purchasing alliance.