Ala. Admin. Code r. 482-1-124-.03

Current through Register Vol. 43, No. 1, October 31, 2024

Section 482-1-124-.03 - Definitions

In addition to the definitions contained in the Trade Practices Act and Section 27-1-2, Code of Ala. 1975, which are incorporated by reference, the following definitions shall apply for purposes of this chapter:

(a) Beneficiary. The party entitled to receive the proceeds or death benefits occurring under the policy in lieu of the insured.

(b) Claim file. Any retrievable electronic file, paper file or combination of both relative to the claim, that may contain:

1. For life insurance and annuities: The file or files containing the notice of claim, claim forms, proofs of loss, medical records, correspondence to and from insureds and claimants or their representatives, claim investigation documentation, claim handling logs, copies of checks or drafts, check numbers and amounts, releases, correspondence, all applicable notices, and correspondence used for determining and concluding claim payments or denials, any written communication, any documented or recorded telephone communication related to the handling of a claim, including the investigation, and any other documentation, maintained in a paper or electronic format, necessary to support claim handling activity.

2. For accident and health insurance: The file or files containing the notice of claim, claim forms, medical records, bills, electronically submitted bills, proofs of loss, correspondence to and from insureds and claimants or their representatives, claim investigation documentation, health facility pre-admission certification or utilization review documentation, claim handling logs, copies of explanation or benefit statements, any written communication, any documented or recorded telephone communication related to the handling of a claim, including the investigation, copies of checks or drafts, or check numbers and amounts, releases, correspondence, all applicable notices, and correspondence used for determining and concluding claim payments or denials, and any other documentation, maintained in a paper or electronic format, necessary to support claim handling activity.

(c) Claimant. An insured, any beneficiary or legal representative of the insured or beneficiary, including an adult member of the insured's or beneficiary's immediate family, designated in writing by the insured or beneficiary making a claim under a policy, subject, however, to the following provisions regarding a minor beneficiary as set forth in Sections 26-1-1, 27-14-5, and 27-14-25, Code of Ala. 1975.

(d) Days. Calendar days, calculated as set forth in the Alabama Rules of Civil Procedure.

(e) Documentation. All pertinent communications, transactions, notes, work papers, claim forms, bills, explanation of benefits forms, and all other records relative to the claim.

(f) Insurer. As set forth in Sections 27-1-2 and 27-1-17, Code of Ala. 1975.

(g) INSURANCE POLICY. As set forth in Section 27-14-1(1), Code of Ala. 1975.

(h) Investigation. All activities of an insurer directly or indirectly related to the determination of liabilities under coverages afforded by an insurance policy, insurance certificate or insurance contract.

(i) NOTICE OR Notification of A claim. Any notice or notification, whether in writing or other means acceptable under the terms of an insurance policy to an insurer by a claimant, which reasonably apprises the insurer of the facts pertinent to a claim.

(j) Proof of loss. Written evidence, including but not limited to claim forms, medical bills, medical authorizations, death certificates or other reasonable evidence of the claim or its circumstances that is ordinarily required by the insurer of all insureds or beneficiaries submitting the claims.

(k) PRODUCER. A person required to be licensed under the laws of this state to sell, solicit or negotiate insurance.

(l) REASONABLE EXPLANATION. Information sufficient to enable the insured or beneficiary to compare the allowable benefits with policy provisions and determine whether proper payment has been made.

(m) WRITTEN COMMUNICATIONS. All correspondence, regardless of source or type, that is materially related to the handling of the claim.

Author: Commissioner of Insurance

Ala. Admin. Code r. 482-1-124-.03

New Rule: May 27, 2003; effective June 9, 2003. Filed with LRS May 30, 2003. Rule is not subject to the Alabama Administrative Procedure Act.

Statutory Authority:Code of Ala. 1975, §§ 27-2-17, 27-1-17, 27-1-19, 27-12-21, 27-12-24, 27-15-13, 27-16-10, 27-17-11, 27-19-11, 27-19-12.