Georgia Claims Adjuster- Insurance Rules and Regulations
An emergency insurance adjuster license in the State of Georgia expires after ____ days.
60 days
According to the general rules for cancellation of insurance policies in Georgia, how many days notice must an insurer give the insured before cancelling a policy?
30 days
If unable to make decision in 15 days, the insurer can take __ more days after notifying claimant
45 more days
Temporary adjuster licenses are valid for up to ___ months, and can be renewed for ___ month periods if necessary. However, they may never be held for longer than ___ months in total.
6 months, 3 months, 15 months
How long are Emergency Adjuster permits valid?
60 days
Insurers are officially rated by:
independent organizations.
The National Association of Insurance Commissioners (NAIC)
is a non-profit coalition of state insurance agencies. It works to harmonize state laws and regulations by drafting model legislation, which is frequently adopted by all or most states.
In Georgia, once an insurer has received all pertinent information about a claim, it must accept or deny the claim within a specified period of time. If the insurer needs more time to come to a decision, it must:
notify the claimant, stating the reasons for the delay.
Cancellation and Nonrenewal - Advance notice required: Insurer refunds unearned premiums to policyholder on _________ basis
pro rata
When Jane is involved in an accident in Georgia, she immediately calls her insurer and files a claim. Her insurer is required by law to do all of the following EXCEPT:
refrain from paying or denying the claim until the claimant submits proof of loss forms.
When an admitted insurer plans to change its rate schedule, it must:
file the change with the state department of insurance for review.
Cancellation and Nonrenewal - Advance notice required: For non-payment of premiums: __ days
10 days
Cancellation and Nonrenewal - Advance notice required: In most cases: __ days
30 days
If arson is suspected, insurer has __ days to affirm or deny coverage
30 days
Covered claims must be paid within __ days after insurer makes a decision
10 days
Taking Disciplinary Action
- Commissioner will inform adjuster or agent in writing - Agent or adjuster can request hearing within 30 days of receiving notice - Commissioner must then schedule hearing & give adjuster/agent 10 days notice - Once license has been refused or revoked, the person is ineligible to apply again for 5 years
Insured's rights under a Guaranty Association:
- Helps policyholders find new insurers as soon as possible - Covers claims already filed or policies that have already been funded - Slower claim resolution: 90 days or more - Policyholders should find new insurance as quickly as possible Note: if an insurer has no guaranty association (e.g. HMOs), the insured is responsible for finding new insurance
Rules for Cancellation & Nonrenewal:
- Insurers must give policyholders 30 days notice - For non-payment of premiums: 10 days notice - Policies in effect for less than 60 days: 10 days notice - Notification must be delivered in person or by first class mail - If sending by mail, insurer must keep receipt
Statutes of Limitations in Georgia include:
- Personal injury: 2 years - Trespassing: 4 years - Fraud: 2 years - Medical malpractice: 2 years - Defamation of character (libel): 1 year
In Georgia, after a policyholder files a claim, the insurer has ______ days to send proof of loss forms.
15 days
Once insurer receives all paperwork, it has __ days to make a decision regarding payment
15 days
The state of Georgia requires that insurers acknowledge receiving a claim and beginning investigating it within ___ days.
15 days
If a claimant in Georgia has completed a proof of loss form, an insurer has ____ days to accept or deny a claim before it must contact the claimant to explain why more time is required. In that case, the insurer has an additional ____ days to make a decision on the claim.
15, 45
Resident Georgia insurance adjusters who have been licensed for less than 20 years are required to complete ____ hours of continuing education every ____ year(s).
24 hours, 2 years
Cancellation and Nonrenewal - Advance notice required: Penalty for not returning unearned premiums on time: __% (plus __% interest)
25%, 18% interest
In Georgia, an individual has ________________ to file a lawsuit for libel.
1 year
To maintain a Certificate of Authority, insurers must:
1. Comply with all insurance laws 2. Be financially sound 3. Give claimants their due 4. Provide necessary access and information for renewal 5. Pay final judgements within 30 days in order to conduct insurance business in the state of Georgia, insurers must have a certificate of authority. Insurers are also required to have a certificate of authority for every agent who represents their company. There are several things insurers need to do to obtain this certificate and keep it current. They must comply with all insurance rules, regulations, and directives of the commissioner; be financially sound; deal with claimants fairly; be open to examination and provide all information necessary for the certificate of authority renewal; and, pay any judgment rendered against them within 30 days.
Insurance and Safety Fire Commissioner
1. Elected position 2. Four year term 3. Can appoint deputies 4. Attorney general decides legality of rules if disputed 5. Must not have financial interest in any insurance company or agency The commissioner is the most senior person in the Office of Insurance, and his or her formal title is Insurance and Safety Fire Commissioner. Elected by the citizens of Georgia to a four year term, the commissioner is responsible for enforcing the laws related to insurance passed by the state legislature. He has the authority to make rules based on the law, and enforce them. Any dispute over whether a rule is legal or not is decided by the state attorney general. The commissioner can appoint deputies to help enforce the laws, including a chief deputy commissioner. Only persons who have no financial interest in any insurance company or agency are eligible to be commissioner.
The Commissioner has the power to:
1. Examine all domestic insurance companies and rating organizations 2. At least every five years, examine agents, sub-agents, brokers, counselors, adjusters, and managers of domestic insurance companies 3. He will schedule a hearing within 30 days of a complaint, if he suspects violation of the law The commissioner has broad powers of investigation that enable him to ensure that insurance companies and agents in Georgia are acting in accordance with the law. At least every five years, he will examine all the domestic insurance companies and rating organizations in the state. He has the authority to look at their transactions, accounts, assets, business methods, and management practices. The commissioner also has the authority to examine agents, sub-agents, brokers, counselors, adjusters, and managers. If he believes that there has been a violation of insurance law, he may schedule a hearing on the matter, and will serve notice of the hearing by registered mail. If the commissioner receives a complaint about an insurance agent or company, and believes the complaint is credible, he will schedule a hearing within 30 days of the complaint, again serving notice by registered mail.
Georgia Requirements
1. Insurers must keep sufficient funds on hand to pay any claims that might arise 2. All Property and Casualty insurers must participate in Georgia Insurers Insolvency Pool 3. All Life and Health insurers must be members of Georgia Life & Health Insurance Guaranty Association The Georgia Office of Insurance requires all admitted insurers to prove that they are financially stable. When an insurer enters into a contract with a policyholder, it has the legal obligation to pay all legitimate claims of that client. So it needs to keep enough funds in reserve to be able to make good on all of its promises. In addition to this, all property and casualty insurers must participate in the Georgia Insurers Insolvency Pool, and all life and health insurers must be members of Georgia Life & Health Insurance Guaranty Association.
Insurance Commissioners' responsibilities
1. Maintaining insurer solvency 2. Regulating rates 3. Protecting consumers 4. Making insurance available for all individuals State commissioners and departments of insurance are responsible for regulating many aspects of the insurance industry (especially those concerning the financial solvency of the insurers doing business in their state). The commissioners and departments oversee the financial stability of insurers and regulate the rates that insurers charge. They also protect consumers and ensure that insurance is available for all individuals.
The Commissioner also has the power to:
1. Prohibit any person he suspects of breaking insurance law from continuing that illegal action 2. Impose penalties against any person found guilty of breaking insurance law, even without a hearing 3. Place any insurer on probation for up to one year for each violation
According to the general rules for cancellation of insurance policies in Georgia, if a policyholder hasn't been paying premiums, how many days notice must an insurer give the insured before cancelling the policy?
10 days
Cancellation and Nonrenewal - Advance notice required: For new policies (less than 60 days in): __ days
10 days
Insurance Guaranty Association
A non-profit association of insurers from similar markets. It is formed and run by the Office of Insurance to make sure that insurers are able to pay claims, even in the event of an insolvency. Each member of a Guaranty Association pays assessments into a common fund. The amount an insurer pays is based on how much it makes in premiums each year. Then, if a member insurer goes broke and cannot pay insurance claims, the Guaranty Association steps in and uses the collected funds to take care of that insurer's policyholders. Most states have two Guaranty Associations: one for Property and Casualty, and one for Life and Health.
Rules for Prompt Settlement
After receiving a claim, the insurer must, within 15 days: -Acknowledge receipt of the claim -Begin investigating circumstances of the claim -Give claimant necessary forms -Request all pertinent information In Georgia, when someone files a claim, the insurer must act promptly, acknowledging receipt of the claim within 15 days.
Third Party Administrators (TPAs)
Although many outside the insurance industry are unaware, insurers commonly outsource a large percentage of their claims adjusting and processing to Third Party Administrators, or TPAs. For example... Because of the huge overflow of claims during Hurricane Katrina, insurers outsourced tens of thousands of overflow claims to TPA's who specialize in handling hurricane claims. It is important to note, however, that a TPA does not assume any of the risk for the policies they handle. Rather, the insurer always retains all risk. Any business entity acting as a TPA must be licensed, and the license must be renewed annually. Failure to acquire the necessary license is grounds for fines and penalties.
Proof of Loss Forms
An insurer must send proof of loss forms to the claimant, not only when the situation calls for them, but also any time a policyholder asks for them in writing. The insurer has 15 days to send these forms to the policyholder, and must include reasonable explanations for how to use them. If the insurer does not send the proof of loss forms, then the insurer has automatically given up its right to require proof of loss forms from the claimant.
Georgia 50% Bar Rule
Another law that can come into play in liability claims is the 50% Bar Rule. As you know, Georgia is a tort state (also called an at-fault state) rather than a no-fault state. This means that, when a loss occurs, the guilty party has to pay for damages. On top of this, Georgia follows the doctrine of modified comparative negligence, which means that if the injured party was partially responsible for the loss, the court will compare the two parties' negligence. If the injured party is at least 50% 'at fault,' they cannot recover damages. If the injured party is less than 50% 'at fault,' then they can recover damages, but the amount of the damages is reduced by the amount that they were at fault. For example... Say Gil ran a red light and got t-boned by James, who was speeding as he drove through the intersection. Since James was speeding, Gil decides to sue him for his medical bills and the damage to his car. However, the court decides that Gil was 80% responsible for the accident, since he ignored the traffic signal. Since he bears more than half of the responsibility, Gil cannot collect any damages from James. On the flip side, if James were to sue Gil for his injuries and property damage, James' damages would be reduced by 20%, since he was 20% responsible for the accident.
Insolvent Insurers - What happens when an insurer gets into financial trouble?
Commissioner can: - Place the insolvent insurer in receivership - Revoke or suspend the insurer's certificate of authority (and notify other states of the actions taken) When an insurer becomes insolvent, the Guaranty Association: - Notifies all of the insurer's policyholders (via mail to the last known address of the insured) - Becomes claim manager - Pays only certain claims, and only up to a set limit When the Commissioner learns that an insurer is impaired or troubled financially, he may place it in receivership. He also has the authority to revoke or suspend the insurer's certificate of authority (in which case he must notify other states that he has done so). If the insurer becomes insolvent, its Guaranty Association becomes claims manager. First, it will notify all policyholders of the insolvent insurer and provide them with directions on how to file a claim with the association. Filing a claim with the association is different from filing claims with the insurer, since the insured often has to duplicate information that he previously sent to the insurer. The Guaranty Association can only pay certain claims, and only up to a set limit. For example, the Georgia Life and Health Insurance Guaranty Association will not pay more than $300,000 on a life insurance claim.
Three Classes of Insurers
Domestic: Based in Georgia Foreign (a.k.a. Surplus): Based in another state Alien: Based outside the United States
Administrative Fines - After a hearing, Commissioner can fine insurers up to $5,000 for regularly:
Encouraging claimants to accept less than they're due Failing to process and pay claims in a timely manner Refusing to pay proper claims Accepting money or gifts to send work to another company
The _________________ is the Federal Law that regulates the collection, dissemination and use of consumer information by insurance companies, credit agencies, and financial institutions.
FCRA- Fair Credit Reporting Act
Georgia Guaranty Associations
Georgia Life and Health Insurance Guaranty Association - Health insurance - Life insurance Georgia Insurers Insolvency Pool - Workers' compensation insurance - Auto insurance - All other kinds of insurance (with a few exceptions) In Georgia, Life and Health insurance is backed by the Georgia Life and Health Insurance Guaranty Association. All health and life insurers must be members in order to operate in Georgia. The Georgia Insurers Insolvency Pool is for Property and Casualty insurers. All direct insurers in Georgia must be members, with exceptions for a few specific types of insurance, such as health and life insurance (since these are members of the Life and Health Guaranty Association), fidelity and surety bonds, ocean marine insurance, and title insurance.
The set of patient privacy rules that all health care providers, insurance companies, physicians offices, hospitals and pharmacies must follow is called the:
HIPAA - Health Insurance Portability and Accountability Act.
The __________________ is the act that specifically regulates the collection and use of your personal information by an insurance provider.
IIPPA- Insurance Information and Privacy Protection Act
Insurers must refund unearned premiums to the policyholder in the case of cancellation:
In the case of a cancellation, any unearned premium that the insured has paid will be refunded on a pro rata basis. The insurer must return this unearned premium on or before the cancellation date either directly to the named insured or to the insured's agent. (If it goes to the insured's agent, then the agent must return the unearned premium to the insured within 10 days or on the date of cancellation, whichever is later.) If an insurer fails to return the unearned premiums, it must pay the insured a penalty equal to 25% of the unearned premium, plus interest of 18% per year until the unearned premiums have been returned. The maximum amount of penalty and interest cannot be more than 50% of the amount of refund due. There are some exceptions to this. The insurer is exempt from this requirement if the cancellation results from the insured's failure to pay premiums; or if the policy specifies a different way of calculating penalties that has been approved by the commissioner.
Georgia Emergency Management Authority (GEMA)
In the event of a Georgia Emergency Management Authority (GEMA) declared disaster, insurers must send by electronic file a list of the non-licensed staff adjusters and out of state adjusters who will be working on disaster related claims. The insurer will then receive a permit allowing the temporary adjusters to work in the state for a maximum of 60 days. In the case of a non-GEMA declared disaster, adjusters licensed in another state can work in Georgia up to 60 days if they notify the Commissioner prior to arriving in the state. They should send their name, address, and anticipated date of arrival. If they will be in the state for more than 60 days, they need to apply for a license to do business in Georgia.
Discovery Rule
In the state of Georgia, many statutes of limitations are based on when an injury is discovered, or when it reasonably should have been discovered. This is called the discovery rule. In some cases, however, this rule does not apply. For example, in the case of Medical Malpractice, the statute of limitations is 2 years after the date of the alleged act, omission, or neglect, except that a minor under 5 years old has until the minor's 7th birthday to file. The statute of limitations for: - Personal injury: 2 years with the discovery rule - Product liability: 2 years with the discovery rule or 1 year from date of death - Fraud: starts when the fraud is discovered Medical Malpractice: Statute of limitations: usually 2 years after the date of the alleged act Exceptions: - when a foreign object is left inside a patient during a surgery, the discovery rule applies - a minor under 5 years old has until the minor's 7th birthday to file
On July 14, 2017, Mark suffered injuries when a kitchen appliance he was using broke apart during operation. In Georgia, what is the last date Mark can file a lawsuit for his injuries?
July 14, 2019
Timely Decisions for Claimants
Once the insurance company receives all the items, statements, and forms necessary to determine financial proof of loss, the insurer then has 15 business days to come to a decision regarding payment on the claim. (If, however, the insurer never required the policyholder to complete a proof of loss form, then the insurer has 30 days from the day the claim was filed to affirm or deny coverage.) If the insurer is unable to come to a decision within 15 days, it must contact the claimant to explain why more time is required. After this notice has been made, the insurer has an additional 45 days to make a decision on the claim. If arson is suspected, the insurance company is given 30 days to affirm or deny coverage. If the insurance company ultimately rejects the claim, it must notify the claimant in writing, explaining why the claim was rejected. Covered claims must be paid within 10 days after the insurer determines the amount of indemnification.
The Insurance Information & Privacy Protection Act (IIPPA)
One of the model laws proposed by the National Association of Insurance Commissioners in 1980, and adopted by most states. Unlike the Fair Credit Reporting Act, which focuses on regulating financial institutions, this act deals specifically with how insurance companies collect, use, and share personal information about their policy holders. IIPPA requires that the insurer provide a statement to the policyholder that explains how they will treat personal information. This statement tells the consumer how his personal information will be safeguarded. The notice also explains how information could be shared and gives the consumer the opportunity to prevent certain information from being shared. IIPPA requires that insurers tell consumers why insurance coverage was declined or why insurance claims were denied. It also mandates that an insurer must give reasonable notice for policy renewal and that it notify clients of other policy changes it implements.
McCarran-Ferguson Act
Passed in 1945, allowing the individual states to regulate the insurance industry
Commissioner's Authority- If an insurer does not follow state laws, the Commissioner can:
Refuse to issue or renew its certificate of authority Revoke or suspend its certificate of authority Place the insurer under administrative supervision The commissioner has the authority to revoke, suspend, or refuse to renew an insurer's certificate of authority if these requirements are not met. He can also place the company under administrative supervision. If the commissioner finds out that an insurance company has proceedings against it in any state for financial distress, or for any other restriction or suspension, he may suspend without notice the company's certificate of authority.
Temporary Licenses
The Commissioner can grant temporary licenses if necessary: - Renewed at 3 month intervals - May not exceed 15 months in total Situations that may require temporary licenses: - An adjuster or agent becomes ill, disabled, or dies - An adjuster or agent is away at military service If the commissioner thinks that the situation warrants it, he can grant temporary agent or adjuster licenses, which do not require an exam, and are valid for up to 6 months. He might do this if an adjuster dies, becomes ill or disabled, or is away at military service and there is no one else to replace him. This license can be renewed for 3 month periods if the commissioner deems it necessary, but never longer than 15 months in total.
Commissioner can refuse, suspend, or revoke a TPAs license for the following reasons:
The Commissioner reserves the right to refuse, suspend, or revoke the license of a Third Party Administrator for certain unfair or illegal practices. Some acts that can lead to disciplinary action include: violating any state insurance provisions; misrepresenting or concealing facts in an application; obtaining or attempting to obtain a license by fraud; misappropriating or illegally withholding money belonging to an insurer, insured, or beneficiary; committing fraudulent or dishonest insurance practices; misrepresenting the terms and conditions of insurance policies; violating any order, rule, or regulation of the Commissioner; not carrying on business in good faith as an administrator; failing to maintain an adequate net worth as prescribed by the Commissioner for licensure and renewal; and failing to demonstrate trustworthiness and competence as an administrator.
Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act, or HIPAA, was enacted by the U.S. Congress in 1996. HIPAA deals mainly with the portability of health insurance.
Elements of a TPA application:
The state of Georgia takes the licensure of Third Party Administrators very seriously. In order to become licensed in Georgia, a TPA must pay a fee and submit an application, along with several other documents. These include, among other things, the company's Articles of Incorporation; its by-laws; a description of the applicant's business plan; a list of the current officers and directors with relevant information for each; financial statements from the past two calendar years; a $100,000 surety bond; and a $100,000 errors and omissions insurance policy. Both the bond and the insurance policy must be maintained the entire time the TPA license is in place and for an entire year after the TPA license expires. This in-depth application process ensures that only competent TPAs are licensed, since TPAs are often responsible for important aspects of the insurance business. For example, they can collect premiums, adjust and settle claims, handle claims funds, underwrite policies, and pre- certify or pre-authorize hospitalizations on behalf of the insurer.
Cancellation by the Insured
When the policyholder wants to cancel an insurance policy, she can simply return the policy to the insurer or write to the insurance company to let them know the date on which she'd like the policy to be cancelled. When it receives a cancellation request from a policyholder, the insurance company must send the insured a receipt confirming the date and time the policy will be cancelled. If there is a third party involved, such as a mortgage company, governmental agency, or lender, they also will receive notice, at least ten days before the cancellation is effective. In the event that the insurance company fails to cancel the policy as requested, it will automatically be cancelled as soon as the policyholder has a replacement policy with the same or similar coverage.
Fair Debt Collection Practices Act, or FDCPA
Works with this act to protect consumers' credit rights in the United States.
Five years ago, when Rosamund was one year old, she had an expensive procedure done to remove what a doctor said was a cancerous tumor behind her knee. Her parents have recently discovered, upon the return of her condition, that the growth was merely a harmless cyst and not a dangerous tumor. Will the Statute of Limitations allow her parents to file a suit against the doctor?
Yes; suits for Medical Malpractice are allowed until the child's 7th birthday.
The Fair Credit Reporting Act or FCRA
a federal law that regulates how consumers' personal and financial information is collected, shared, and used by companies. The main focus of this law is to regulate credit agencies and financial institutions, but insurance companies are also affected by this law. It was originally passed in 1970, and is enforced by the U.S. Federal Trade Commission. This law is also enforced by private lawsuits.
Libel
a published false statement that is damaging to a person's reputation; a written defamation.
