N.M. Admin. Code § 13.7.3.12

Current through Register Vol. 35, No. 24, December 23, 2024

Section 13.7.3.12 - COMPLAINT RECORD - EXPLANATION

A.A - Company identification number: As noted, this refers to the company's identification number of the complaint or other means or identifying the complaint, and shall also include the license number or other means of identifying any licensee of the department of insurance (such as agent, adjuster or independent adjuster) whose conduct or records are involved in the complaint.

B.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.

C.B - 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 an application for insurance resulted in company action involved in the complaint);

(c) cancellation;

(d) rescission;

(e) non-renewal;

(f) premiums and rating;

(g) delays;

(h) refusal to insure;

(i) miscellaneous (not covered by above).

(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) agent handling;

(d) replacement;

(e) dividend illustration;

(f) delays;

(g) alleged misleading statement or misrepresentation;

(h) miscellaneous (not covered by above).

(3)Claims:

(a) claims procedure;

(b) delays;

(c) unsatisfactory settlements;

(d) natural disaster adjusting (hurricane or flood situations which produce a large number of claims);

(e) unsatisfactory settlement offer;

(f) denial of claim;

(g) miscellaneous (not covered by above).

(4)Policyholder service:

(a) failure to respond;

(b) delays;

(c) miscellaneous (not covered by above).

(5)Miscellaneous: Not covered in 13 NMAC 7.3.12.3.1 through 13 NMAC 7.3.12.3.4 [now Paragraphs (1) through (4) of Subsection C of 13.7.3.12 NMAC].

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

(1) automobile;

(2) fire;

(3) homeowners - farmowners;

(4) crop;

(5) inland marine;

(6) individual life;

(7) group life;

(8) annuities;

(9) individual accident and health;

(10) group accident and health;

(11) workers' compensation;

(12) liability insurance other than automobile;

(13) mobile homeowners;

(14) miscellaneous (not covered by above).

E.D - Company disposition after receipt: The complaint record shall note the disposition of the complaint. The following examples illustrate the type of information called for, but are not intended to be required language nor to exhaust the possibilities: corrective action was taken; no action was deemed necessary; or a satisfactory explanation was given to the complainant. If the company wishes it may use a code for entries in this column.

F.E - Date received: This refers to the date the complaint was received.

G.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.

H.G - Insurance department complaint: If the origin of the complaint was from an insurance department, it should be so identified.

I.H - State of origin: The complaint record should note the state from which the complaint originated. Ordinarily this will be the state of residence of the complainant.

N.M. Admin. Code § 13.7.3.12

7/1/97; Recompiled 11/30/01