Tenn. Comp. R. & Regs. 0780-01-05-.04

Current through December 10, 2024

Section 0780-01-05-.04 - DEFINITIONS

All definitions contained in the Tennessee Unfair Trade Practices and Unfair Claims Settlement Act of 2009, T.C.A. title 56, chapter 8, part 1, are hereby incorporated by reference. As otherwise used in this Chapter, the following definitions apply unless otherwise specifically defined herein:

(1) "Beneficiary" means the party entitled to receive the proceeds or benefits occurring under the policy of the insured;

(2) "Claim" means:

(a)

1. An oral, written, or electronic submission for payment that is filed by an insured , on behalf of an insured, or by a third party where the insurer accepts such claims, in accordance with the insurer's reasonable submission standards; and

2. Is sufficient to reasonably establish contractual liability for payment on the part of the insurer;

(b) For the purposes of T.C.A. § 56-8-105, a "claim" does not mean an inquiry by an insured as to the existence of coverage or how a potential claim may affect future premiums or renewability of coverage;

(3) "Claim file" means any retrievable electronic file, paper file, or combination of both, relative to a specific claim made by or on behalf of a claimant with an insurer;

(4) "Commissioner" means the commissioner of the department of commerce and insurance;

(5) "Days" means calendar days unless otherwise noted;

(6) "Department" means the department of commerce and insurance;

(7) "Documentation" or "to be documented" includes, but is not limited to, all pertinent communications, transactions, notes, work papers, claim forms, bills and explanation of benefits forms relative to the claim;

(8) "First party claimant" means an individual, corporation, association, partnership or other legal entity asserting a right to payment directly against an insurer under an insurance policy or insurance contract arising out of the occurrence of the contingency or loss covered by the policy or contract;

(9) "Inquiry" means any communication to an insurance company by an insured or by an insurance producer on behalf of an insured, regarding general terms and conditions of the insured's personal residential property policy, including a communication concerning whether an insured's personal residential property policy provides coverage for a type of event or the process for filing a claim;

(10) "Insurance producer" or "producer" means a person required to be licensed under the laws of this state to sell, solicit or negotiate insurance under title 56, chapter 6, part 1;

(11) "Investigation" means all activities of an insurer directly or indirectly related to the determination of liabilities under coverages afforded by an insurance policy or insurance contract;

(12) "Notification of claim" or "notice of claim" means any notification, in writing or other means acceptable under the terms of an insurance policy, to an insurer or its producer by a claimant, which reasonably apprises the insurer of the facts pertinent to a claim;

(13) "Personal residential property policy" means a homeowners insurance policy or a policy otherwise described in T.C.A. §§ 56-5-102(7)(A) and (B);

(14) "Proof of loss" means written proofs, such as claim forms, or other reasonable evidence of the claim that is required of insureds or beneficiaries submitting the claims;

(15) "Reasonable explanation" means information sufficient to enable the insured or beneficiary to compare the allowable benefits with policy provisions and determine whether proper payment has been made;

(16) "Third party claimant" means any person asserting a claim against any person under a policy or certificate of an insurer; and

(17) "Written communication" includes all correspondence, regardless of source or type, that is materially related to the handling of the claim. Written communication also includes electronic mail (email) when requested by the claimant and when accepted by the insurer. Written communication does not include any privileged communication that is prepared by an attorney employed or retained by an insurer, including, but not limited to, work product or legal opinions.

Tenn. Comp. R. & Regs. 0780-01-05-.04

Original rules filed July 11, 2017; effective 10/9/2017.

Authority: T.C.A. §§ 56-2-301, 56-5-302(7)(A) and (B), 56-6-102, 56-7-3403, 56-8-101 through 56-8-120, 56-8-102, 56-8-108, and 56-8-110.