reglab/statecodes huggingface dataset:
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.12 - Minimum Standards for Home Health Care Benefits in Long-Term Care Insurance Policies

Current through June 14, 2024
A. A long-term care
				  insurance policy or certificate may not, if it provides benefits for home
				  health care or community services, limit or exclude benefits:
1. By requiring that the insured/claimant
				  would need skilled care in a skilled nursing facility if home health care
				  services were not provided;
2. By
				  requiring that the insured/claimant first or simultaneously receive nursing
				  and/or therapeutic services in a home, community or institutional setting
				  before home health care services are covered;
3. By limiting eligible services to services
				  provided by registered nurses or licensed practical nurses;
4. By requiring that a nurse or therapist
				  provide services covered by the policy that can be provided by a home health
				  aide, or other licensed or certified home care worker acting within the scope
				  of his or her licensure or certification;
5. By excluding coverage for personal care
				  services provided by a home health aide;
6. By requiring that the provision of home
				  health care services be at a level of certification or licensure greater than
				  that required by the eligible service;
7. By requiring that the insured/claimant
				  have an acute condition before home health care services are covered;
8. By limiting benefits to services provided
				  by Medicare-certified agencies or providers.
9. By excluding coverage for adult day care
				  services.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.13 - Requirement to Offer Inflation Protection

Current through June 14, 2024
A. No issuer may
				  offer a long-term care insurance policy unless the issuer also offers to the
				  policyholder in addition to any other inflation protection the option to
				  purchase a policy that provides for benefit levels to increase with benefit
				  maximums or reasonable durations which are meaningful to account for reasonably
				  anticipated increases in the costs of long-term care services covered by the
				  policy. Issuers must offer to each policyholder, at the time of purchase, the
				  option to purchase a policy with an inflation protection feature no less
				  favorable than one of the following:
1.
				  Increases benefit levels annually in a manner so that the increases are
				  compounded annually at a rate not less than five percent (5%);
2. Guarantees the insured individual the
				  right to periodically increase benefit levels without providing evidence or
				  insurability or health status so long as the option for the previous period has
				  not been declined. The amount of the additional benefit shall be no less than
				  the difference between the existing policy benefit and that benefit compounded
				  annually at a rate of at least five percent (5%) for the period beginning with
				  the purchase of the existing benefit and extending until the year in which the
				  offer is made; or
3. Covers a
				  specified percentage of actual or reasonable charges and does not include a
				  maximum specified indemnity amount or limit.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.14 - Requirements for Application Forms and Replacement Coverage

Current through June 14, 2024
A. Application forms shall include the
				  following questions designed to elicit information as to whether, as of the
				  date of the application, the applicant has another long-term care insurance
				  policy or certificate in force or whether a long-term care policy or
				  certificate is intended to replace any other accident and sickness or long-term
				  care policy or certificate presently in force. A supplementary application or
				  other form to be signed by the applicant and producer, except where the
				  coverage is sold without a producer, containing the questions may be used. With
				  regard to a replacement policy issued to a group defined by R.I. Gen. Laws
				  §
										27-34.2-4(4)(i),
				  the following questions may be modified only to the extent necessary to elicit
				  information about health or long-term care insurance policies other than the
				  group policy being replaced, provided that the certificate-holder has been
				  notified of the replacement.
1. Do you have
				  another long-term care insurance policy or certificate in force (including
				  health care service contract, health maintenance organization
				  contract)?
2. Did you have another
				  long-term care insurance policy or certificate in force during the last twelve
				  (12) months?
a. If so, with which
				  company?
b. If that policy lapsed,
				  when did it lapse?
3.
				  Are you covered by Medicaid?
4. Do
				  you intend to replace any of your medical or health insurance coverage with
				  this policy [certificate]?
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.15 - Reporting Requirements

Current through June 14, 2024
A. Every issuer
				  shall maintain records for each producer of that producer's amount of
				  replacement sales as a percent of the producer's total annual sales and the
				  amount of lapses of long-term care insurance policies sold by the producer as a
				  percent of the producer's total annual sales.
B. Every issuer shall report annually by June
				  30 the ten percent (10%) of its producers with the greatest percentages of
				  lapses and replacements as measured by §
										1.15(A)   of this Part. (Appendix G
				  provided in a Bulletin issued for the purpose of designating the forms required
				  to be used by this Part)
C.
				  Reported replacement and lapse rates do not alone constitute a violation of
				  insurance laws or necessarily imply wrongdoing. The reports are for the purpose
				  of reviewing more closely producer activities regarding the sale of long-term
				  care insurance.
D. Every issuer
				  shall report annually by June 30 the number of lapsed policies as a percent of
				  its total annual sales and as a percent of its total number of policies in
				  force as of the end of the preceding calendar year. (Appendix G provided in a
				  Bulletin issued for the purpose of designating the forms required to be used by
				  this Part)
E. Every issuer shall
				  report annually by June 30 the number of replacement policies sold as a percent
				  of its total annual sales and as a percent of its total number of policies in
				  force as of the preceding calendar year. (Appendix G provided in a Bulletin
				  issued for the purpose of designating the forms required to be used by this
				  Part)
F. Every issuer shall report
				  annually by June 30 for qualified long-term care insurance contracts, the
				  number of claims denied for each class of business, expressed as a percentage
				  of claims denied. (Appendix E provided in a Bulletin issued for the purpose of
				  designating the forms required to be used by this Part)
G. For purposes of this section:
1. "Policy" means only long-term care
				  insurance;
2. Subject to
				  §
											1.15(G)(3)   of this Part, "Claim" means a request for payment of benefits
				  under an in-force policy regardless of whether the benefit claimed is covered
				  under the policy or any terms or conditions of the policy have been
				  met;
3. "Denied" means the issuer
				  refuses to pay a claim for any reason other than for claims not paid for
				  failure to meet the waiting period or because of an applicable preexisting
				  condition; and
4. "Report" means on
				  a statewide basis.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.16 - Licensing

Current through June 14, 2024
A producer is not authorized to sell, solicit or negotiate
					 with respect to long-term care insurance except as authorized by R.I. Gen. Laws
					 Chapter 27-2.4.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.17 - Discretionary Powers of Commissioner

Current through June 14, 2024
A. The director may
				  upon written request and after an administrative hearing, issue an order to
				  modify or suspend a specific provision or provisions of this Part with respect
				  to a specific long- term care insurance policy or certificate upon a written
				  finding that:
1. The modification or
				  suspension would be in the best interest of the insureds;
2. The purposes to be achieved could not be
				  effectively or efficiently achieved without the modification or suspension;
				  and
3. The modification or
				  suspension is necessary to the development of an innovative and reasonable
				  approach for insuring long-term care; or
4. The policy or certificate is to be issued
				  to residents of a life care or continuing care retirement community or some
				  other residential community for the elderly and the modification or suspension
				  is reasonably related to the special needs or nature of such a community;
				  or
5. The modification or
				  suspension is necessary to permit long-term care insurance to be sold as part
				  of, or in conjunction with, another insurance product.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.18 - Reserve Standards

Current through June 14, 2024
A. When long-term
				  care benefits are provided through the acceleration of benefits under group or
				  individual life policies or riders to such policies, policy reserves for the
				  benefits shall be determined in accordance with R.I. Gen. Laws Chapter
				  27-4.5.
B. Claim reserves shall
				  also be established in the case when the policy or rider is in claim
				  status.
C. Reserves for policies
				  and riders subject to this subsection should be based on the multiple decrement
				  model utilizing all relevant decrements except for voluntary termination rates.
				  Single decrement approximations are acceptable if the calculation produces
				  essentially similar reserves, if the reserve is clearly more conservative, or
				  if the reserve is immaterial. The calculations may take into account the
				  reduction in life insurance benefits due to the payment of long-term care
				  benefits. However, in no event shall the reserves for the long-term care
				  benefit and the life insurance benefit be less than the reserves for the life
				  insurance benefit assuming no long-term care benefit.
D. In the development and calculation of
				  reserves for policies and riders subject to this subsection, due regard shall
				  be given to the applicable policy provisions, marketing methods, administrative
				  procedures and all other considerations which have an impact on projected claim
				  costs, including, but not limited to, the following:
1. Definition of insured events;
2. Covered long-term care
				  facilities;
3. Existence of home
				  convalescence care coverage;
4.
				  Definition of facilities;
5.
				  Existence or absence of barriers to eligibility;
6. Premium waiver provision;
7. Renewability;
8. Ability to raise premiums;
9. Marketing method;
10. Underwriting procedures;
11. Claims adjustment procedures;
12. Waiting period;
13. Maximum benefit;
14. Availability of eligible
				  facilities;
15. Margins in claim
				  costs;
16. Optional nature of
				  benefit;
17. Delay in eligibility
				  for benefit;
18. Inflation
				  protection provisions; and
19.
				  Guaranteed insurability option.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.19 - Loss Ratio

Current through June 14, 2024
A. This section
				  shall apply to all long-term care insurance policies or certificates except
				  those covered under §§
										1.10,  1.20  and  1.21   of this Part.
B. Benefits under long-term care insurance
				  policies shall be deemed reasonable in relation to premiums provided the
				  expected loss ratio is at least sixty percent (60%), calculated in a manner
				  which provides for adequate reserving of the long-term care insurance risk. In
				  evaluating the expected loss ratio, due consideration shall be given to all
				  relevant factors, including:
1. Statistical
				  credibility of incurred claims experience and earned premiums;
2. The period for which rates are computed to
				  provide coverage;
3. Experienced
				  and projected trends;
4.
				  Concentration of experience within early policy duration;
5. Expected claim fluctuation;
6. Experience refunds, adjustments or
				  dividends;
7. Renewability
				  features;
8. All appropriate
				  expense factors;
9.
				  Interest;
10. Experimental nature
				  of the coverage;
11. Policy
				  reserves;
12. Mix of business by
				  risk classification; and
13.
				  Product features such as long elimination periods, high deductibles and high
				  maximum limits.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.20 - Premium Rate Schedule Increases

Current through June 14, 2024
A. This section
				  shall apply as follows:
1. Except as provided
				  in §
											1.20(A)(2)   of this Part below, this section applies to any long-term
				  care policy or certificate issued in this state on or after December 1, 2008
				  and prior to January 1, 2019.
2.
				  For certificates issued on or after the effective date of this amended Part
				  under a group long-term care insurance policy as defined in R.I. Gen. Laws
				  §
											27-34.2-4(4)(i),
				  which policy was in force at the time this amended Part became effective, the
				  provisions of this section shall apply on the policy anniversary following June
				  1, 2009.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.21 - Filing Requirements

Current through June 14, 2024
Prior to an issuer offering group long-term care insurance
					 to a resident of this state pursuant to R.I. Gen. Laws §
										27-34.2-5, it shall file with the
					 Director a copy of the certificate and the outline of coverage, along with
					 evidence that the group policy or certificate thereunder has been approved by a
					 state having statutory or regulatory long-term care insurance requirements
					 substantially similar to those adopted in this state.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.22 - Filing Requirements for Advertising

Current through June 14, 2024
A. Every issuer
				  providing long-term care insurance or benefits in this state shall provide a
				  copy of any long-term care insurance advertisement intended for use in this
				  state whether through written, radio or television medium to the director for
				  review or approval by the director to the extent it may be required under state
				  law. In addition, all advertisements shall be retained by the issuer for at
				  least three (3) years from the date the advertisement was first used.
B. The director may exempt from these
				  requirements any advertising form or material when, in the director's opinion,
				  this requirement may not be reasonably applied.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.23 - Standards for Marketing

Current through June 14, 2024
A. Every issuer
				  marketing long-term care insurance coverage in this state, directly or through
				  its producers, shall:
1. Establish marketing
				  procedures and producer training requirements to assure that:
a. Any marketing activities, including any
				  comparison of policies, by its producers or other producers will be fair and
				  accurate; and
b. Excessive
				  insurance is not sold or issued.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.24 - Suitability

Current through June 14, 2024
A. This section shall not apply to life
				  insurance policies that accelerate benefits for long-term care.
B. Every issuer marketing long-term care
				  insurance shall:
1. Develop and use
				  suitability standards to determine whether the purchase or replacement of
				  long-term care insurance is appropriate for the needs of the
				  applicant;
2. Train its producers
				  in the use of its suitability standards; and
3. Maintain a copy of its suitability
				  standards and make them available for inspection upon request by the
				  director.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.25 - Prohibition Against Preexisting Conditions and Probationary Periods in Replacement Policies or Certificates

Current through June 14, 2024
If a long-term care insurance policy or certificate
					 replaces another long-term care policy or certificate, the replacing issuer
					 shall waive any time periods applicable to preexisting conditions and
					 probationary periods in the new long-term care policy for similar benefits to
					 the extent that similar exclusions have been satisfied under the original
					 policy.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.26 - Availability of New Services or Providers

Current through June 14, 2024
A. An issuer
				  shall notify policyholders of the availability of a new long-term policy series
				  that provides coverage for new long-term care services or providers material in
				  nature and not previously available through the issuer to the general public.
				  The notice shall be provided within twelve (12) months of the date of the new
				  policy series is made available for sale in this state.
B. Notwithstanding §
										1.26(A)   of this Part
				  above, notification is not required for any policy issued prior to the
				  effective date of this Section or to any policyholder or certificate holder who
				  is currently eligible for benefits, within an elimination period or on a claim,
				  or who previously had been in claim status, or who would not be eligible to
				  apply for coverage due to issue age limitations under the new policy. The
				  issuer may require that policyholders meet all eligibility requirements,
				  including underwriting and payment of the required premium to add such new
				  services or providers.
C. The
				  issuer shall make the new coverage available in one of the following ways:
1. By adding a rider to the existing policy
				  and charging a separate premium for the new rider based on the insured's
				  attained age;
2. By exchanging the
				  existing policy or certificate for one with an issue age based on the present
				  age of the insured and recognizing past insured status by granting premium
				  credits toward the premiums for the new policy or certificate. The premium
				  credits shall be based on premiums paid or reserves held for the prior policy
				  or certificate;
3. By exchanging
				  the existing policy or certificate for a new policy or certificate in which
				  consideration for past insured status shall be recognized by setting the
				  premium for the new policy or certificate at the issue age of the policy or
				  certificate being exchanged. The cost for the new policy or certificate may
				  recognize the difference in reserves between the new policy or certificate and
				  the original policy or certificate; or
4. By an alternative program developed by the
				  issuer that meets the intent of this Section if the program is filed with and
				  approved by the Director.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.27 - Right to Reduce Coverage and Lower Premiums

Current through June 14, 2024
A. Every
				  long-term care insurance policy and certificate shall include a provision that
1. allows the policyholder or certificate
				  holder to reduce coverage and lower the policy or certificate premium in at
				  least one of the following ways:
a. Reducing
				  the maximum benefit; or
b. Reducing
				  the daily, weekly or monthly benefit amount.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.28 - Nonforfeiture Benefit Requirement

Current through June 14, 2024
A. This section does
				  not apply to life insurance policies or riders containing accelerated long-term
				  care benefits.
B. To comply with
				  the requirement to offer a nonforfeiture benefit pursuant to the provisions of
				  R.I. Gen. Laws §
										27-34.2-19:
1. A policy or certificate offered with
				  nonforfeiture benefits shall have coverage elements, eligibility, benefit
				  triggers and benefit length that are the same as coverage to be issued without
				  nonforfeiture benefits. The nonforfeiture benefit included in the offer shall
				  be the benefit described in §
											1.28(E)   of this Part; and
2. The offer shall be in writing if the
				  nonforfeiture benefit is not otherwise described in the Outline of Coverage or
				  other materials given to the prospective policyholder.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.29 - Standards for Benefit Triggers

Current through June 14, 2024
A. A long-term care
				  insurance policy shall condition the payment of benefits on a determination of
				  the insured's ability to perform activities of daily living and on cognitive
				  impairment. Eligibility for the payment of benefits shall not be more
				  restrictive than requiring either a deficiency in the ability to perform not
				  more than three (3) of the activities of daily living or the presence of
				  cognitive impairment.
B. Activities
				  of daily living shall include at least the following as defined in §
										1.5   of
				  this Part and in the policy:
1.
				  Bathing;
2. Continence;
3. Dressing;
4. Eating;
5. Toileting; and
6. Transferring.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.30 - Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts

Current through June 14, 2024
A. For purposes of
				  this section the following definitions apply:
1. "Qualified long-term care services" means
				  services that meet the requirements of Section  7702(c)(1)   of the Internal
				  Revenue Code of 1986 (26
				  U.S.C. §
												7702(c)(1)),
				  as amended, as follows: necessary diagnostic, preventive, therapeutic,
				  curative, treatment, mitigation and rehabilitative services, and maintenance or
				  personal care services which are required by a chronically ill individual, and
				  are provided pursuant to a plan of care prescribed by a licensed health care
				  practitioner.
2. "Chronically ill
				  individual" has the meaning prescribed for this term by section  7702B(c)(2)   of
				  the Internal Revenue Code of 1986 (26 U.S.C. §
												7702B(c)(2)), as amended.
				  Under this provision, a chronically ill individual means any individual who has
				  been certified by a licensed health care practitioner as:
(a) Being unable to perform (without
				  substantial assistance from another individual) at least two (2) activities of
				  daily living for a period of at least ninety (90) days due to a loss of
				  functional capacity; or
(b)
				  Requiring substantial supervision to protect the individual from threats to
				  health and safety due to severe cognitive impairment.
(c) The term "chronically ill individual"
				  shall not include an individual otherwise meeting these requirements unless
				  within the preceding twelve-month period a licensed health care practitioner
				  has certified that the individual meets these requirements.
3. "Licensed health care
				  practitioner" means a physician, as defined in Section  1861(r)(1)   of the Social
				  Security Act (42 U.S.C.
				  1395x), a registered professional nurse,
				  licensed social worker or other individual who meets requirements prescribed by
				  the Secretary of the Treasury.
4.
				  "Maintenance or personal care services" means any care the primary purpose of
				  which is the provision of needed assistance with any of the disabilities as a
				  result of which the individual is a chronically ill individual (including the
				  protection from threats to health and safety due to severe cognitive
				  impairment).
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.32 - Prompt Payment of Clean Claims

Current through June 14, 2024
A. For purposes of
				  this section:
1. "Claim" means a request for
				  payment of benefits under an in-force policy, regardless of whether the benefit
				  claimed is covered under the policy or any terms or conditions of the policy
				  have been met.
2. "Clean claim"
				  means a claim that has no defect or impropriety, including any lack of required
				  substantiating documentation, such as satisfactory evidence of expenses
				  incurred, or particular circumstance requiring special treatment that prevents
				  timely payment from being made on the claim.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 35 - Long Term Care Insurance › Part 1 - Long Term Care Insurance (formerly Insurance Regulation 44) › Section 230-RICR-20-35-1.33 - Requirement to Deliver Shoppers Guide

Current through June 14, 2024
A. A long-term care
				  insurance shopper's guide in the format developed by the National Association
				  of Insurance Commissioners, or a guide developed or approved by the director,
				  shall be provided to all prospective applicants of a long-term care insurance
				  policy or certificate.
1. In the case of
				  producer solicitations, a producer must deliver the shopper's guide prior to
				  the presentation of an application or enrollment form.
2. In the case of direct response
				  solicitations, the shopper's guide must be presented in conjunction with any
				  application or enrollment form.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 40 - Claims › Part 1 - Unfair Life, Accident and Health Claims Settlement Practices (230-RICR-20-40-1) › Section 230-RICR-20-40-1.1 - Authority

Current through June 14, 2024
This Part is promulgated under the authority of R.I. Gen.
					 Laws §
										27-9.1-8. This Part does not apply
					 to claims subject to R.I. Gen. Laws §§
										27-18-61,
					 27-19-52,
					 27-20-47 or
					 27-41-64. This Part applies only
					 to individuals and entities subject to the jurisdiction of the Department of
					 Business Regulation and not those subject to the jurisdiction of the Office of
					 the Health Insurance Commissioner as indicated in R.I. Gen. Laws §§
										42-14-5(d) and
					 42-14.5-1 et
					 seq.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 40 - Claims › Part 1 - Unfair Life, Accident and Health Claims Settlement Practices (230-RICR-20-40-1) › Section 230-RICR-20-40-1.2 - Purpose

Current through June 14, 2024
The purpose of this Part is to set forth minimum standards
					 for the investigation and disposition of life, accident and health claims
					 arising under policies or certificates issued pursuant to State law. It is not
					 intended to cover claims involving workers' compensation insurance. The various
					 provisions of this part are intended to define procedures and practices which
					 constitute unfair claims practices. Nothing herein shall be construed to create
					 or imply a private cause of action for violation of this part. This is merely a
					 clarification of original intent and does not indicate of any change of
					 position.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 40 - Claims › Part 1 - Unfair Life, Accident and Health Claims Settlement Practices (230-RICR-20-40-1) › Section 230-RICR-20-40-1.3 - Definitions

Current through June 14, 2024
A. All definitions contained in R.I. Gen.
				  Laws Chapter 27-9.1. The Unfair Claims Settlement Practices Act are hereby
				  incorporated by reference. As otherwise used in this part:
1. "Agent" means any individual, corporation,
				  association, partnership or other legal entity authorized to represent an
				  insurer with respect to a claim;
2.
				  "Beneficiary" means the party entitled to receive the proceeds or benefits
				  occurring under the policy in lieu of the insured;
3. "Claim file" means any retrievable
				  electronic file, paper file or combination of both;
4. "Claimant" means an insured, the
				  beneficiary or legal representative of the insured, including a member of the
				  insured's immediate family designated by the insured, making a claim under a
				  policy;
5. "Days" means calendar
				  days;
6. "Documentation" includes,
				  but is not limited to, all pertinent communications, transactions, notes, work
				  papers, claim forms, bills and explanation of benefits forms relative to the
				  claim;
7. "Investigation" means all
				  activities of an insurer directly or indirectly related to the determination of
				  liabilities under coverages afforded by an insurance policy or insurance
				  contract;
8. "Notification of a
				  claim" means any notification, whether in writing or other means acceptable
				  under the terms of an insurance policy to an insurer or its agent, by a
				  claimant, which reasonably apprises the insurer of the facts pertinent to a
				  claim;
9. "Proof of loss" means
				  written proofs, such as claim forms, medical bills, medical authorizations or
				  other reasonable evidence of the claim that is ordinarily required of all
				  insureds or beneficiaries submitting the claims;
10. "Reasonable explanation" means
				  information sufficient to enable the insured or beneficiary to compare the
				  allowable benefits with policy provisions and determine whether proper payment
				  has been made;
11. "Written
				  communications" includes all correspondence, regardless of source or type, that
				  is materially related to the handling of the claim.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 40 - Claims › Part 1 - Unfair Life, Accident and Health Claims Settlement Practices (230-RICR-20-40-1) › Section 230-RICR-20-40-1.5 - File and Record Documentation

Current through June 14, 2024
A. Each insurer's
				  claim files for policies or certificates are subject to examination by the
				  Director or by his or her duly appointed designees. To aid in the examination:
1. The insurer shall maintain claim data that
				  are accessible and retrievable for examination. An insurer shall be able to
				  provide the claim number, line of coverage, date of loss and date of payment of
				  the claim, date of denial or date closed without payment. This data shall be
				  available for all open and closed files for the current year and the two (2)
				  preceding years.
2. Detailed
				  documentation shall be contained in each claim file in order to permit
				  reconstruction of the insurer's activities relative to each claim.
3. Each document within the claim file shall
				  be noted as to date received, date processed or date mailed.
4. For those insurers that do not maintain
				  hard copy files, claim files must be accessible from a computer monitor or
				  micrographics and be capable of being printed as hard copy.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 40 - Claims › Part 1 - Unfair Life, Accident and Health Claims Settlement Practices (230-RICR-20-40-1) › Section 230-RICR-20-40-1.6 - Severability

Current through June 14, 2024
If any provision of this part or the application thereof to
					 any person or circumstances is held invalid or unconstitutional, the invalidity
					 or unconstitutionality shall not affect other provisions or applications of
					 this part which can be given effect without the invalid or unconstitutional
					 provision or application, and to this end the provisions of this part are
					 severable.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 40 - Claims › Part 2 - Unfair Property/Casualty Claims Settlement Practices › Section 230-RICR-20-40-2.1 - Authority

Current through June 14, 2024
This Part is adopted under the authority of R.I. Gen. Laws
					 Chapter 27-9.1.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 40 - Claims › Part 2 - Unfair Property/Casualty Claims Settlement Practices › Section 230-RICR-20-40-2.2 - Purpose

Current through June 14, 2024
The purpose of this Part is to establish minimum standards
					 for the investigation and disposition of property and casualty claims arising
					 under insurance policies or certificates as defined in this Part and issued to
					 residents of Rhode Island. It is not intended to cover claims involving
					 workers' compensation, fidelity, suretyship, or boiler and machinery insurance.
					 The various provisions of this Part are intended to define procedures and
					 practices which constitute unfair claims practices. Nothing herein shall be
					 construed to create nor imply a private cause of action for violation of this
					 part. This is merely a clarification of original intent and does not indicate
					 any change of position.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 40 - Claims › Part 2 - Unfair Property/Casualty Claims Settlement Practices › Section 230-RICR-20-40-2.4 - File and Record Documentation

Current through June 14, 2024
A. Each insurer's
				  claim files for policies or certificates are subject to examination and
				  investigation by the Director or by the Director's duly appointed designees. To
				  aid in such examination:
1. The insurer shall
				  maintain claim data that is accessible and retrievable for examination. An
				  insurer shall be able to provide the claim number, line of coverage, date of
				  loss and date of payment of the claim, date of denial or date closed without
				  payment. This data must be available for all open files and for closed files
				  for the current year and four (4) preceding years.
2. Detailed documentation shall be contained
				  in each claim file in order to permit reconstruction of the insurer's
				  activities relative to each claim.
3. Each relevant document within the claim
				  file shall be noted as to date received, date processed, or date
				  mailed.
4. For those insurers that
				  do not maintain hard copy files, claim files must be in appropriate electronic
				  media and be capable of duplication to hard copy.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 40 - Claims › Part 2 - Unfair Property/Casualty Claims Settlement Practices › Section 230-RICR-20-40-2.5 - Misrepresentation of Policy Provisions

Current through June 14, 2024
A. No insurer shall
				  fail to fully disclose to first party claimants all pertinent benefits,
				  coverages, or other provisions of a policy or contract under which a claim is
				  presented.
B. No agent shall
				  conceal from first party claimants benefits, coverages or other provisions of
				  any insurance policy or insurance contract when such benefits, coverages or
				  other provisions are pertinent to a claim.
C. A first party claim shall not be denied on
				  the basis of failure to exhibit property unless there is documentation of
				  breach of the policy provisions in the claim file.
D. No insurer shall deny a claim based upon
				  the failure of a first party claimant to give written notice of loss within a
				  specified time limit unless the written notice is a written policy condition,
				  or first party claimant's failure to give written notice after being requested
				  to do so is so unreasonable as to constitute a breach of the first party
				  claimant's duty to cooperate with the insurer.
E. No insurer shall indicate to a first party
				  claimant on a payment draft, check or in any accompanying letter that said
				  payment is "final" or "a release" of any claim or specified part of a claim
				  unless the policy limit has been paid or there has been a compromise settlement
				  agreed to by the first party claimant and the Insurer as to coverage and amount
				  payable under the contract.
F. No
				  insurer shall issue checks or drafts in partial settlement of a loss or claim
				  under a specific coverage that contains language purporting to release the
				  insurer or it's insured from total liability.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 40 - Claims › Part 2 - Unfair Property/Casualty Claims Settlement Practices › Section 230-RICR-20-40-2.6 - Failure to Acknowledge Pertinent Communications

Current through June 14, 2024
A. Every insurer, upon receiving notification
				  of claim shall, within fifteen (15) days acknowledge the receipt of such notice
				  in writing unless payment is made within that period of time.
B. In addition to the requirements in
				  §
										2.6(A)   of this Part, the insurer upon receiving notification of claim
				  shall inform the claimant in the insurer's written acknowledgment of receipt of
				  the claim, or sooner if the claimant inquires, if coverage exists for the
				  rental of an automobile comparable to the claimant's damaged vehicle.
C. Every insurer, upon receipt of any inquiry
				  from the Department regarding a claim shall, within twenty-one (21) days of
				  receipt of such inquiry, furnish the Department with an adequate written
				  response to the inquiry.
D. An
				  appropriate reply in writing shall be made within fifteen (15) days on all
				  other pertinent communications from a claimant which reasonably suggest that a
				  response is expected.
E. Upon
				  request by an Automobile Body Shop, an insurer must notify the Automobile Body
				  Shop of the name(s), address(es), telephone number(s) of any lienholder(s) on
				  the vehicle which is the subject of the claim.
F. Every insurer, upon receiving notification
				  of claim, shall promptly provide necessary claim forms, instructions and
				  reasonable assistance so that first party claimants can comply with the policy
				  conditions and the insurer's reasonable requirements. Compliance with this
				  paragraph within fifteen (15) days of notification of a claim shall constitute
				  compliance with §
										2.6(A)   of this Part.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 40 - Claims › Part 2 - Unfair Property/Casualty Claims Settlement Practices › Section 230-RICR-20-40-2.7 - Standards for Prompt, Fair and Equitable Settlements Applicable to All Insurers

Current through June 14, 2024
A. Within
				  twenty-one (21) days after receipt by the insurer of properly executed proofs
				  of loss, the first party claimant shall be advised of the acceptance or denial
				  of the claim by the Insurer. No insurer shall deny a claim on the grounds of a
				  specific provision, condition, or exclusion unless reference to such provision,
				  condition, or exclusion is included in the denial. The denial must be given to
				  the first party claimant in writing and the claim file of the insurer shall
				  contain such documentation of the denial as required by §
										2.4   of this Part.
1. Where there is a reasonable basis
				  supported by specific information available for review by the Department that
				  the first party claimant has fraudulently caused or contributed to the loss,
				  the insurer is relieved from the requirements of this subsection; provided,
				  however, that the first party claimant shall be advised of the acceptance or
				  denial of the claim within a reasonable time for full investigation after
				  receipt by the insurer of a properly executed proof of loss.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 40 - Claims › Part 2 - Unfair Property/Casualty Claims Settlement Practices › Section 230-RICR-20-40-2.9 - Standards for Prompt, Fair and Equitable Settlements Applicable to Fire and Extended Coverage Type Policies with Replacement Cost Coverage

Current through June 14, 2024
A. Replacement Cost
1. When the insurance policy provides for the
				  adjustment and settlement of first party claimant losses based on replacement
				  cost, the following shall apply:
a. When a
				  loss requires repair or replacement of an item or part, any consequential
				  physical damage incurred in making such repair or replacement not otherwise
				  excluded by the policy, shall be included in the loss. The first party claimant
				  shall not have to pay for betterment nor any other cost except for the
				  applicable deductible.
b. When a
				  loss requires replacement of items and the replaced items do not match in
				  quality, color or size, the insurer shall replace all such items so as to
				  conform to a reasonably uniform appearance. This applies to interior and
				  exterior losses. The first party claimant shall not bear any cost over the
				  applicable deductible, if any.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 40 - Claims › Part 2 - Unfair Property/Casualty Claims Settlement Practices › Section 230-RICR-20-40-2.10 - Department Complaint Review

Current through June 14, 2024
A. A claimant who
				  believes that there has been a violation of this Part may file a written
				  complaint with the Division. All complaints filed with the Department shall be
				  processed in accordance with the Division's internal complaint review process
				  and, if the Division determines that reasonable cause exists, the complaint
				  shall be handled in accordance with the Department's Rules of Procedure for
				  Administrative Hearings, Part 10-00-2 of this Title.
B. All complaints filed with Department must
				  be in writing. The Department will only accept complaints filed by the
				  individual claimant, the claimant's designated immediate family member (spouse,
				  parent, sibling or offspring), an insurance producer licensed by the Department
				  with regard to policies of insurance effected by him or her, claimant's
				  attorney admitted to practice law in this state, executor and/or administrator
				  or other court-appointed legal representative of the claimant's estate. If a
				  complaint relates to a claim which is under consideration by any court of this
				  or any other state, the Division may defer jurisdiction over the matter to that
				  court. Nothing herein shall be deemed to prohibit either the insurer or the
				  claimant from seeking redress in the appropriate judicial forum.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 45 - Financial Standards and Corporate Operations › Part 1 - Insurance Holding Company Systems (230-RICR-20-45-1) › Section 230-RICR-20-45-1.1 - Authority

Current through June 14, 2024
This Part is promulgated pursuant to the authority granted
					 by R.I. Gen. Laws §
										27-35-7.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 45 - Financial Standards and Corporate Operations › Part 1 - Insurance Holding Company Systems (230-RICR-20-45-1) › Section 230-RICR-20-45-1.2 - Purpose

Current through June 14, 2024
The purpose of this Part is to set forth rules and
					 procedural requirements which the Commissioner deems necessary to carry out the
					 provisions of R.I. Gen. Laws Chapter 27-35. The information called for by this
					 Part is hereby declared to be necessary and appropriate in the public interest
					 and for the protection of the policyholders in this State.
Rhode Island Code of Regulations › Title 230 - Department of Business Regulation › Chapter 20 - Insurance › Subchapter 45 - Financial Standards and Corporate Operations › Part 1 - Insurance Holding Company Systems (230-RICR-20-45-1) › Section 230-RICR-20-45-1.3 - Severability Clause

Current through June 14, 2024
If any provision of this Part, or the application thereof
					 to any person or circumstance, is held invalid, such determination shall not
					 affect other provisions or applications of this Part which can be given effect
					 without the invalid provision or application, and to that end the provisions of
					 these regulations are severable.