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Beginning an insurance company case may help prevent a “bad” insurance adjuster from causing harm to some other person, especially during a time of tragedy caused by a personal injury or the wrongful death of a loved one.
We handle insurance company cases involving:
Forcing an insurance company to pay a disputed claim requires determination and strategy. Here are a few of the steps from beginning to end:
Insurance company cases require quick attention from an experienced personal injury lawyer or wrongful death attorney. Mike Burman and Burman Law have the paralegal staff and financial resources needed to take on any insurance company. Mike will work with you to:
Insurance companies and insurance adjusters use several tactics to deny claims and pay less than the value of the claim. Some of the most common we see are:
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Kentucky Administrative Regulations
Title 806 - PUBLIC PROTECTION CABINET - DEPARTMENT OF INSURANCE
Chapter 12 - Trade Practices and Frauds
Section 806 KAR 12:095 - Unfair claims settlement practices for property and casualty insurance
Current through Register Vol. 49, No. 3, September 1, 2022
RELATES TO: KRS 304.2-100, 304.2-165, 304.2-340, 304.3-200(1)(e), 304.12-010, 304.12-220, 304.12-230, 304.12-235, 304.14-400, 304.20-070, 304.20-150 to 304.20-180, 342.325
NECESSITY, FUNCTION, AND CONFORMITY: KRS 304.2-110 authorizes the Commissioner of Insurance to make reasonable administrative regulations necessary for, or as an aid to, the effectuation of any provision of the Kentucky Insurance Code. This administrative regulation establishes unfair property and casualty insurance claims settlement practices, effectuating KRS 304.3-200(1)(e), 304.12-010, and 304.12-230.
Section 1. Definitions.
(1) "Agent" means any person authorized to represent an insurer with respect to a claim;
(2) "Claimant" means either a first-party claimant, a third-party claimant, or both and includes:
(a) The claimant's designated legal representative, including an administrator, executor, guardian, or similar person, and
(b) A member of the insured's immediate family designated by the claimant;
(3) "Claim file" means any retrievable electronic file, paper file, or both;
(4) "Commissioner" is defined by KRS 304.1-050(1);
(5) "Days" means any day, Monday through Friday, except holidays;
(6) "First-party claimant" means a person asserting a right to payment under an insurance policy, certificate, or contract arising out of the occurrence of the contingency or loss covered by the policy, certificate, or contract;
(7) "Insurer" is defined by KRS 304.1-040;
(8) "Investigation" means all activities of an insurer related to the determination of liabilities under coverages afforded by a policy, certificate, or contract;
(9) "Local market area" means a reasonable distance surrounding the area where a motor vehicle is principally garaged or the usual location of the article covered by the policy. This area does not mean limited to the geographic boundaries of the Commonwealth;
(10) "Notification of claim" means any notification, whether in writing or by other means acceptable under the terms of the policy, certificate, or contract, to an insurer or its agent, by a claimant, which reasonably apprises the insurer of the facts pertinent to a claim;
(11) "Policy", "certificate", or "contract" means any contract of insurance or indemnity, except for:
(a) Fidelity, suretyship, or boiler and machinery insurance; or
(b) A contract of workers' compensation insurance unless it satisfies the requirements of Section 2 of this administrative regulation.
(12) "Replacement crash part" means sheet metal or plastic parts which generally constitute the exterior of a motor vehicle, including inner and outer panels; and
(13) "Third-party claimant" means any person asserting a claim against any person under a policy, contract, or certificate of an insurer.
Section 2. Scope and Purpose of this Administrative Regulation.
(1) This administrative regulation establishes:
(a) Minimum standards for the investigation and disposition of property and casualty insurance claims arising under policies, certificates, and contracts;
(b) Procedures and practices which constitute unfair claims settlement practices; and
(c) Standards for the commissioner in investigations, examinations, and administrative adjudication and appeals.
(2) This administrative regulation shall not cover claims involving:
(a) Fidelity, suretyship, or boiler and machinery insurance; or
(b) Workers' compensation unless:
1. The claim involves a question that does not arise under KRS Chapter 342; or
2. The claim is for unearned premium refunds.
(3) Statement of enforcement policy. If complaints are filed with the commissioner, the commissioner shall note violations of this administrative regulation after the insurer or agent has been given an opportunity to pay the claim and any interest.
(4) A violation of this administrative regulation shall be found only by the commissioner. This administrative regulation shall not create or imply a private cause of action for violation of this administrative regulation.
Section 3. File and Record Documentation. Each insurer's claim files for policies, certificates, or contracts are subject to examination by the commissioner or the commissioner's designees. To aid in an 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, and 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 five (5) preceding years.
(2) The insurer shall maintain documentation in each claim file to permit reconstruction of the insurer's activities relative to each claim.
(3) The insurer shall note each relevant document within the claim file as to date received, date processed, or date mailed.
(4) If an insurer does not maintain hard copy files, claim files shall be accessible to examiners electronically and be capable of duplication to legible hard copy.
Section 4. Misrepresentation of Policy Provisions.
(1) Insurers and agents shall not misrepresent or conceal from first-party claimants any pertinent benefits, coverages, or other provisions of any insurance policy or insurance contract if the benefits, coverages, or other provisions are pertinent to a claim, pursuant to KRS 304.12-230(1).
(2) Insurers shall not deny a claim on the basis of failure to exhibit property unless there is documentation in the claim file of a breach of the policy provisions.
(3) Insurers shall not deny a claim based upon the failure of a first-party claimant to give written notice of loss within a specified time limit unless written notice of loss is a written condition in the policy, certificate, or contract and the 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.
(4) Insurers shall not indicate to a first-party claimant on a payment draft, check, or in an accompanying letter that payment is "final" or "a release" of any claim unless:
(a) The policy limit has been paid; or
(b) There has been a compromise settlement agreed to by the first-party claimant and the insurer as to coverage and amount payable under the policy, certificate, or contract.
(5) Insurers shall not issue checks or drafts in partial settlement of a loss or claim under a specific coverage which contain language which releases the insurer or its insured from total liability.
Section 5. Failure to Acknowledge Pertinent Communications.
(1) Every insurer, upon receiving notification of a claim shall, within fifteen (15) days, acknowledge the receipt of the notice unless payment is made within that period of time. If an acknowledgement is made by means other than writing, an appropriate notation of the acknowledgement shall be made in the claim file of the insurer and dated. Notification given to an agent of an insurer shall be notification to the insurer.
(2) If an insurer receives an inquiry from the Department of Insurance respecting a claim, the insurer shall, within fifteen (15) days of receipt of the inquiry, furnish the Department of Insurance with an adequate response to the inquiry in duplicate.
(3) The insurer shall make an appropriate reply within fifteen (15) days on all other pertinent communications from a claimant which reasonably suggest that a response is expected.
(4) Every insurer, upon receiving notification of claim, shall promptly provide necessary claim forms, instructions, and reasonable assistance to first-party claimants so that they can comply with the policy conditions and the insurer's reasonable requirements. Compliance with this subsection within fifteen (15) days of notification of a claim shall constitute compliance with subsection (1) of this section.
Section 6. Standards for Prompt, Fair, and Equitable Settlements Applicable to All Insurers.
(a) Except as provided in this subsection, an insurer shall, offer any payment due within thirty (30) calendar days of receipt of proof of loss. If claims involve multiple coverages, payments which are not in dispute shall be tendered within thirty (30) calendar days of receipt of proof of loss.
(b) If there is a reasonable basis, which shall be supported by specific information available for review by the commissioner, that a claimant has fraudulently caused or contributed to the loss, the insurer shall advise the first-party claimant 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.
(c) If the insurer needs more time to determine whether a first-party claim shall be accepted or denied, it shall notify the first-party claimant within thirty (30) calendar days after receipt of the proofs of loss, giving the reasons more time is needed.
(d) If the investigation remains incomplete, the insurer shall, forty-five (45) calendar days from the date of the initial notification and every forty-five (45) calendar days thereafter, send to the first-party claimant a letter stating the reasons additional time is needed for investigation.
(2) Insurers shall not fail to settle first-party claims on the basis that responsibility for payment shall be assumed by others except as may otherwise be provided by policy provisions.
(3) Insurers shall not continue negotiations for settlement of a claim directly with a first- party claimant who is not legally represented if the first-party claimant's rights may be affected by a statute of limitations or a time limit in a policy, certificate, or contract, unless the insurer has given the first-party claimant written notice of the limitation. The notice shall be given to the first party claimant at least thirty (30) calendar days before the date on which the time limit expires.
(4) Insurers shall not make statements which indicate that the rights of a third-party claimant may be impaired if a form or release is not completed within a given period of time unless the statement is given for the purpose of notifying the third-party claimant of the provision of a statute of limitations.
(5) Subject to subsection (1)(a) of this section relating to first-party claims, insurers shall affirm or deny liability on claims within a reasonable time and shall tender payment within thirty (30) days of affirmation of liability, if the amount of the claim is determined and not in dispute. If claims involve multiple coverages, and if the payee is known, payments which are not in dispute shall be tendered within thirty (30) calendar days.
(6) Insurers shall not request or require any insured to submit to a polygraph examination unless authorized under the applicable policy, certificate, contract, or applicable law.
19 Ky.R. 340; Am. 783; 1380; eff. 12-9-92; 28 Ky.R. 709; 1136; eff. 11-12-2001; TAm eff. 8-9-2007; Crt eff. 2-26-2020; 47 Ky.R. 2717; 48 Ky.R. 827; eff. 11-30-2021.
STATUTORY AUTHORITY: KRS 304.2-110