Or. Admin. Code § 836-043-0071

Current through Register Vol. 63, No. 12, December 1, 2024

Section 836-043-0071 - Dispute Resolution Procedures

(1)

(a) A bona fide premium dispute is established when the employer or its representative provides:

(A) Written notice to the Plan Administrator that includes all of the following:

(i) All documentation relevant to the dispute, including written notice to the insurer or the servicing carrier detailing the specific areas of dispute;

(ii) Description of the attempts to reconcile the differences; and

(iii) A specific request for a review of all documentation, appropriate action to resolve the areas of dispute and if necessary, a hearing before the appropriate administrative or regulatory body having jurisdiction over assigned risk related appeals.

(B) An estimate of the premium the employer believes to be correct, with an explanation of the premium calculation.

(C) Verification of payment of the undisputed portion of the premium provided to the servicing carrier or insurer, and the Plan Administrator.

(b) If the premium in dispute is in litigation, the employer shall provide documentation to the Plan Administrator.

(c) The Plan Administrator shall notify the servicing carrier when a bona fide premium dispute is confirmed. Upon notification, the servicing carrier shall act according to the Plan Administrator's direction pending the resolution of the dispute. The Plan Administrator may direct the servicing carrier to:

(A) Suspend collection activity;

(B) Suspend cancellation if a dispute exists prior to the effective date of cancellation; or

(C) For policies already cancelled, refer to rules set forth in by the Plan Administrator.

(2) Any assigned risk policyholder and the producer of an assigned risk policyholder affected by the actions of their servicing carrier or NCCI shall follow the procedures set forth in ORS 731.240, 737.340 or 737.505 to review, resolve or request a hearing on any grievance.

(a) An individual employer dispute is subject to ORS 731.240, 737.340 or 737.505 as applicable and the conditions outlined in the Bona Fide Premium Dispute and Undisputed Premium Obligation. The intervention of the Plan Administrator in a dispute is limited to matters involving:

(A) Experience rating modification factors;

(B) Application of rules contained in NCCI manuals;

(C) Eligibility and assignment under the Workers' Compensation Insurance Plan;

(D) Classification assignments;

(E) Assigned risk pricing programs; or

(F) A dispute involving other matters arising under the Plan.

(b) Upon receipt of all necessary information regarding the dispute, the Plan Administrator shall review the matter and provide a written decision within 30 days.

(3)

(a) When an employer dispute concerns any of the above matters, other than the application of NCCI's rating plan rules, or involves more than one state, the Plan Administrator shall determine the appropriate jurisdiction for the dispute to be heard, based upon the following factors:

(A) Governing state which shall be the state generating the greatest payroll;

(B) The state covered by the servicing carrier with the greatest exposure insured;

(C) The state where the operations are best represented; or

(D) In accordance with the following jurisdiction table: [Table not included. See ED. NOTE.]

(b) When a dispute concerns the application of NCCI's rules for interstate rated risks, the Plan Administrator shall determine the appropriate jurisdiction for the dispute to be heard.

(c) Unless state-specific rules apply, the ruling of the state appeals mechanism (as determined by the Plan Administrator to have jurisdiction over the dispute) will apply to all assigned risk policies whether written by one or more servicing carriers.

(4) Upon receipt of all necessary information regarding the dispute, the Plan Administrator shall review disputes relating to the calculation or payment of producer fees and producer of record changes and provide a written decision within 30 days.

(5)

(a) Any Plan participant who has a dispute with respect to any aspect of the Plan or Reinsurance Agreement including any dispute arising out of the organizing principles must first seek a review of the matter under this section by providing the following to the Plan Administrator:

(A) Written documentation detailing specific areas of the dispute;

(B) Specific request for a review of all documentation; and

(C) Appropriate actions of areas to resolve the dispute.

(b) The Plan Administrator may request additional information necessary to make a decision. All disputes submitted to the Plan Administrator are governed as follows:

(A) For disputes relating to the general operation of the Plan, including but not limited to, performance standards for servicing carrier performance, compensation and incentives and application assignment determination, the Plan Administrator shall review the matter and provide a written decision within 30 days of receipt of all necessary information regarding the dispute.

(B) Within 30 days after the Plan Administrator makes a decision and at the expense of the party, a party affected by the decision may submit a written request for binding arbitration or the party may seek a de novo review by the Insurance Commissioner.

(C) For any de novo review, the Insurance Commissioner shall follow the procedures provided in ORS 183.310 to 183.540 and 737.360 for review of a contested case.

(D) For a dispute relating to the servicing carrier selection process, refer to the Bid Protest Procedures contained in the applicable servicing carrier Request for Proposal (RFP).

(6)

(a) Within 30 days after receipt of all necessary information regarding a dispute that arises under the organizing principles or a Reinsurance Agreement, the Plan Administrator or the administrator of the Reinsurance Agreement shall review the matter and provide a detailed written decision. Any party affected by the decision may request the board to review the decision by submitting a written request for review within 30 days after the date of the decision by the Reinsurance Administrator under the organizing principles. The board may:

(A) Consider the matter and render its written decision pursuant to the procedures set forth in the organizing principles, or

(B) Waive its decision and offer the aggrieved party the option of appealing directly to the Insurance Commissioner or submitting the dispute to arbitration in accordance with the terms and conditions established by the board.

(b) Any party affected by a decision of the board may seek a de novo review by the Insurance Commissioner by submitting a written request for review, within 30 days after the date of the board decision.

(c) If the dispute relates to the expulsion of a participating company under the organizing principles by the board or the noncontinuation of the reinsurance afforded under the organizing principles, the party may take the appeal directly to the Insurance Commissioner pursuant to ORS 737.360 without first complying with the procedures contained in this rule. The Insurance Commissioner has exclusive jurisdiction over all such disputes. For a review under this paragraph, the Insurance Commissioner shall follow the procedures provided in ORS 183.310 to 183.540 and 737.360 applicable to review of a contested case.

Or. Admin. Code § 836-043-0071

ID 18-2008, f. 12-9-08, cert. ef. 1-1-09

Tables referenced are available from the agency.

Stat. Auth.: ORS 656.427, 656.730 & 731.244

Stats. Implemented: ORS 656.527, 656.730 & 737.265