Section 926.EXHIBIT B   Explanation

 

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A.        Identification Number.  As noted, this refers to the identification number of complaint and shall also include the license number or other means of identifying any licensee of the Insurance Department (such as an insurance producer) that may have been involved in the complaint.

 

B.         Function Code.  Complaints are to be classified by function(s) of the company involved.  Separate classifications are to be maintained for underwriting, marketing and sales, claims, policyholder service and miscellaneous.

Reason Code.  Complaints are also to be classified by the nature of the complaint.  The following is the classification required for each function specified above.

 

1.         Underwriting

 

a)         Company underwriting

 

b)         Individual's application underwriting (this refers to any complaint where misrepresentations or declarations in the application for insurance 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 above)

 

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 which 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 covered by above)

 

3)         Claims

 

a)         Claims procedure

 

b)         Delays

 

c)         Unsatisfactory settlements

 

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

 

e)         Unsatisfactory settlement offers

 

f)          Denial of claim

 

g)         Miscellaneous (not covered by above)

 

4)         Policyholder service

 

a)         Failure to respond

 

b)         Delays

 

c)         Return of premium

 

d)         Miscellaneous (not covered by above)

 

e)         Continuation – State or Federal

 

5)         miscellaneous

 

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

 

1)         Automobile – Personal

 

2)         Automobile – Commercial

 

3)         Homeowners – Farmowners – Mobile Homeowners – Dwelling

 

4)         Commercial Property

 

5)         Inland Marine

 

6)         Individual Life

 

7)         Group Life

 

8)         Annuities

 

9)         Individual Health – Accident & Sickness

 

10)         Group Health – Accident & Sickness

 

11)         HMO individual or group

 

12)         LHSO

 

13)         Workmen's Compensation

 

14)         General/Professional liability

 

15)         Miscellaneous (not covered by above)

 

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 State of Illinois 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.

 

F.         Date Closed.  This refers to the date on which the complaint was disposed of whether by one action or a series of actions as may be present in connection with some complaints.

 

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.

 

(Source:  Amended at 23 Ill. Reg. 5695, effective May 3, 1999)