Washington Administrative Code › Title 284 - Insurance Commissioner, Office of the › Chapter 284-54 - Long-term care insurance rules › Section 284-54-800 - Unfair or deceptive acts

Current through Register Vol. 24-14, July 15, 2024
RCW  48.84.910 authorizes the
				commissioner to prohibit particular unfair or deceptive acts in the conduct of
				the advertising, sale, and marketing of long-term care policies and contracts.
				The purpose of this section is to define certain minimum standards which
				insurers should meet with respect to long-term care. If the following standards
				are violated with such frequency as to indicate a general business practice by
				an insurer, it will be deemed to constitute an unfair method of competition or
				a deceptive act by such insurer and a violation of this section.
(1) Misrepresenting pertinent facts or
			 insurance contract provisions.
(2)
			 Failing to acknowledge and act reasonably promptly upon communications with
			 respect to communications arising under insurance policies or
			 contracts.
(3) Failing to adopt and
			 implement reasonable standards for the prompt investigation of claims arising
			 under insurance policies or contracts.
(4) Refusing to pay claims or provide
			 benefits without conducting a reasonable investigation.
(5) Failing to affirm or deny coverage of
			 claims within a reasonable time.
(6) Compelling an insured to institute
			 litigation to recover amounts due under an insurance contract by offering
			 substantially less than the amounts ultimately recovered in actions brought by
			 such an insured.
(7) Attempting to
			 settle a claim for less than the amount to which a reasonable person would have
			 believed he was entitled by reference to written or printed advertising
			 material accompanying or made part of an application.
(8) Making claims payments to an insured or
			 beneficiaries not accompanied by an explanation setting forth the coverage
			 under which the payments are being made.
(9) Failing to promptly provide a reasonable
			 explanation of the basis in the insurance contract in relation to the facts or
			 applicable law for denial of a claim or for the offer of a compromise
			 settlement.
(10) Asserting to an
			 insured or claimant a policy of appealing from arbitration awards in favor of
			 an insured or claimant for the purpose of compelling them to accept settlements
			 or compromises less than the amount awarded in arbitration.
(11) Delaying the investigation or payment of
			 claims by unreasonably requiring an insured, claimant, or the attending
			 physician of the patient to submit a preliminary claim report and then
			 requiring subsequent submissions which contain substantially the same
			 information.
(12) Failure to
			 expeditiously honor drafts given in settlement of claims within three working
			 days of notice of receipt by the payor bank except for reasons acceptable to
			 the commissioner.
(13) Failure to
			 adopt and implement reasonable standards for the processing and payment of
			 claims once the obligation to pay has been established.
(14) Issue checks or drafts in partial
			 payment of a loss or claim under a specific coverage which contain language
			 which appear to release the insurer from its total liability.
(15) Failure to reply to the insurance
			 commissioner within fifteen working days of receipt of an inquiry, such reply
			 to furnish the commissioner with an adequate response to the inquiry.
(16) Failure to settle a claim on the basis
			 that responsibility for payment should be assumed by others except as may
			 otherwise be provided by policy provisions as permitted by this
			 chapter.
(17) Making statements
			 which indicate the rights of persons may be impaired if a form or release is
			 not completed within a given time unless the statement otherwise is provided by
			 policy provisions or is for the purpose of notifying that person of the
			 provisions of an applicable statute of limitations.
Statutory Authority:
				  RCW
				  48.02.060(3),
				  48.30.010 and
				  48.84.910. 87-15-027 (Order R
				  87-7), §
										284-54-800, filed
				  7/9/87.