18 Del. Admin. Code § 801-3.0

Current through Register Vol. 28, No. 5, November 1, 2024
Section 801-3.0 - Definitions
3.1 For the purpose of this regulation, the following definitions shall apply:

"Claim Administration" - The endorsement shall provide for administration by the insurer in the same manner as for policies without a deductible. This shall include payment by the insurer to the claimant of the deductible amount. The insurer shall have full discretion for claim settlement as provided by the Delaware Workmen's Compensation Code and shall make payments to the claimant or medical provider in accordance with that statute.

"Deductible" - The deductible shall be as elected by the insured at the inception or renewal of the policy, such election to be irrevocable for the duration of the policy. The deductible shall be: any amount between $500 and $5,000 (increments of $500); applied separately to each occurrence regardless of the number of employees; applicable only to medical reimbursements and death benefits paid under the policy.

"Endorsement" - Refers to an endorsement prepared and filed by the Delaware Compensation Rating Bureau on behalf of insurers writing workmen's compensation insurance in Delaware and approved by the Delaware Insurance Department. The endorsement shall specify the amount of the deductible; the coverage to which it applies; shall give notice to the insured of the insurer's discretion in claims settlement; contain provisions for reimbursement of the deductible by the employer; and shall put the employer on notice that the coverage may be cancelled for failure to reimburse the insurer for any payment involving the deductible.

"Occurrence" - An occurrence shall be defined as any incident which results in a payment by an insurer under a workmen's compensation policy. An occurrence may result in claims by multiple employees in which case only one deductible is applicable to all claims growing out of a single incident or occurrence.

"Reimbursement to the Insurer" - Shall refer to payment of the deductible amount by the insured to the insurer for first dollar claim payments (medical reimbursement or death benefits only) made by the insurer on behalf of the employer.

18 Del. Admin. Code § 801-3.0