Ill. Admin. Code tit. 50, pt. 926, exh. B

Current through Register Vol. 48, No. 49, December 6, 2024

Exhibit B - Explanation

Column

A. Identification Number. As noted, this refers to the identification number of the complaint.

B. Reason Code. Complaints are to be classified by the nature of the complaint within one of the involved company's functions of underwriting, marketing and sales, claims, policyholder service, and miscellaneous. The following is the classification required for each function:

1) Underwriting

a) Company underwriting

b) Individual's application underwriting (this refers to any complaint regarding misrepresentations or declarations in the application for insurance that resulted in company action involved in the complaint)

c) Cancellation

d) Recission

e) Non-renewal

f) Premiums and rating

g) Delays

h) Refusal to insure

i) Miscellaneous (not covered by B(1)(a) through (h))

j) Creditable coverage re: Health Insurance Portability and Accountability Act (HIPAA)

k) Late enrollee (HIPAA)

l) Special enrollment (HIPAA)

m) Renewability (HIPAA)

2) Marketing and Sales

a) General advertising

b) Mass marketing advertising (advertising that is essentially directed to reach more people than in a one-to-one relationship)

c) Insurance producer handling

d) Replacement

e) Delays

f) Alleged misleading statement or misrepresentation

g) Miscellaneous (not otherwise covered by this B(2))

3) Claims

a) Claims procedure

b) Delays

c) Unsatisfactory settlements

d) Natural disaster adjusting (hurricane, flood or other situations that produce a large number of claims)

e) Unsatisfactory settlement offers

f) Denial of claim

g) Miscellaneous (not otherwise covered by this B(3))

4) Policyholder service

a) Failure to respond

b) Delays

c) Return of premium

d) Miscellaneous (not covered by B(4)(a) through (c))

e) Continuation - State or federal

5) Miscellaneous

C.Coverage Code. Complaints are to be classified according to the line of insurance involved, as follows:

1) Automobile - Personal

2) Automobile - Commercial

3) Homeowners - Farmowners - Mobile or Manufactured Homeowners - Dwelling

4) Commercial Property

5) Inland Marine

6) Individual Life

7) Group Life

8) Annuities

9) Individual Health - Accident & Sickness (including PPO)

10) Group Health - Accident & Sickness (including PPO)

11) HMO individual or group

12) Limited Health Service Organizations (LHSO)

13) Workers' Compensation

14) General/Professional liability

15) Miscellaneous (not otherwise covered by this C)

D.Company Disposition After Complaint Receipt. The complaint record shall note the disposition of the complaint. The following examples are recommended, but are not intended to be required language nor to exhaust the possibilities. These examples are taken from the form used by the Department of Insurance.

1) Corrective action was taken

a) Rate problem resolved

b) Cancellation withdrawn

c) Non-renewal rescinded

d) Policy restored (Life/A & H)

e) Policy issued

f) Premium refunded

g) Additional monies paid (claims)

h) Coverage extended (claims)

i) Claim reopened

j) Claim settled

k) Cash surrender paid

l) Referral approved

m) Provider changed

2) No action was deemed necessary

a) Contract provisions

b) Questions of fact

c) Policy not in force

d) Cancellation upheld

e) Non-renewal upheld

f) Return premium correct

g) Insufficient information (from complainant)

3) Information was furnished to complainant

E. Date Received. This refers to the date the complaint was received by the insurer.

F. Date Closed. This refers to the date on which the complaint was disposed of by the insurer, whether by one action or a series of actions.

G. Insurance Department Complaint. Complaints are to be classified so as to indicate if the origin of the complaint was from an insurance department.

H. State of Origin. The complaint record shall note the state from which the complaint originated. Ordinarily, this will be the state of residence of the complainant.

Ill. Admin. Code tit. 50, pt. 926, exh. B

Amended at 23 Ill. Reg. 5695, effective May 3, 1999

Amended at 43 Ill. Reg. 3246, effective 2/25/2019