NEW YORK STATE
SECOND AMENDMENT TO REGULATION 95
(11 NYCRR 86)
REPORT OF SUSPECTED INSURANCE FRAUDS TO
INSURANCE FRAUDS BUREAU;
REQUIRED WARNING STATEMENTS
I, NEIL D. LEVIN, Superintendent of Insurance of the State
of New York, pursuant to the authority granted by Sections 201, 301, 403(d) and (e), 409
and 4322 of the Insurance Law, do hereby promulgate the following Second Amendment to Part
86 of Title 11 of the Official Compilation of Codes, Rules and Regulations (Regulation No.
95) to take effect on July 1, 1998.
(New Matter underscored, Deleted Matter in Brackets)
Section 86.2 is hereby amended to read as follows:
The following shall govern the construction of the terms used in this Part:
|(a)||Claimant means any person who attempts to obtain a benefit from an insurer or self-insurer.|
|(b)||Commercial insurance means insurance other than personal insurance.|
|(c)||Insurance policy has the meaning assigned to insurance contract by section 1101 of the Insurance Law, except it shall also include reinsurance contracts, purported insurance policies, self- insurance plans and purported reinsurance contracts.|
|(d)||Insured means the named insured, as defined in the policy, or an applicant for insurance.|
|(e)||Insurer means an insurer authorized to do an insurance business in this State, including any organization exempted from compliance with the licensing requirements by the Insurance Law which is engaged in the business of insurance in this State. For the purpose of this Part, all health maintenance organizations, the Motor Vehicle Accident Indemnification Corporation, the New York Automobile Insurance Plan, the New York Property Insurance Underwriting Association, the Medical Malpractice Insurance Association and the underwriting members of the New York Insurance Exchange, Inc. shall be deemed insurers.|
|(f)||Person includes any individual, firm, association or corporation.|
|(g)||Personal insurance means a policy of insurance
insuring a natural person against any of the following contingencies:
A policy of insurance which insures any of the contingencies listed in paragraphs (1) through (5) of this subdivision, as well as other contingencies, shall be personal insurance if that portion of the annual premium attributable to the listed contingencies exceeds that portion attributable to other contingencies.
|(h)||Statement includes, but is not limited to, any notice, proof of loss, bill of lading, invoice, account, estimate of property damages, bill for services, diagnosis, prescription, hospital or medical provider records, X-ray, test result and other evidence of loss, injury or expenses.|
|(i)||Claim form includes any document supplied by an insurer or self-insurer, directly or indirectly, to a claimant which the claimant is required to complete or submit in support of a claim for benefits.|
Section 86.4 is hereby amended to read as follows:
§86.4 Warning statements.
|(a)||All applications provided to applicants for
[non-automobile] commercial insurance and all claim forms for insurance, except
personal automobile insurance, delivered to any person residing or located in
this State (on and after February 2, 1994) in connection with commercial insurance
policies to be issued or issued for delivery in this State shall contain the following
"Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."
|(b)||All claim forms for personal automobile insurance
delivered to any person residing or located in this State (on and after February 2, 1994)
in connection with policies of personal automobile insurance and claims arising under
policies of such insurance shall contain the following statement:
"Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation."
|(c)||Self-insurers may adopt one or both of the required warning statements set forth in (a) and (b), above on their claim forms.|
|(d)||Location of warning statements and type size.
[(d)] (e) Notwithstanding the provisions of subdivisions (a) and (b) of this section, insurers may use substantially similar warning statements provided such warning statements are submitted to the Insurance Frauds Bureau for prior approval.
Section 86.5 is hereby amended to read as follows:
§86.5 Reports of fraudulent acts.
Any person licensed pursuant to the provisions of the Insurance Law who determines that an insurance transaction or purported insurance transaction appears to be fraudulent or suspect shall submit a report thereon to the Insurance Frauds Bureau. Reports shall be submitted on the prescribed reporting form [(IFB-1) contained in this section or upon the form developed by the United States Department of Justice upon a determination that a matter is suspect. The forms annexed hereto are hereby approved for use as specified in this Part] issued by the Insurance Frauds Bureau or upon any other form approved by order of the superintendent. Reporting may also be done by means of any electronic medium or system approved by order of the superintendent.
Section 86.6 is hereby renumbered to 86.7, and a new section 86.6 is hereby enacted to read as follows:
§86.6 Fraud prevention plans and special investigation units.
|(a)||Every insurer writing private or commercial automobile insurance, workers compensation insurance, or individual, group or blanket accident and health insurance policies issued or issued for delivery in this state, which writes three thousand or more of such policies in any given year, or in the case of policies issued on a group basis, provides insurance coverage for three thousand or more individuals in any given year, shall develop and file with the superintendent a plan for the detection, investigation and prevention of fraudulent insurance activities in this state and those fraudulent insurance activities affecting policies issued or issued for delivery in this state. Notwithstanding the foregoing, insurers writing only reinsurance contracts shall not be required to comply with the provisions of this section.|
|(b)||The plan shall include the following provisions:
|(c)||Persons employed by Special Investigations Units as investigators or by an independent provider of investigative services under contract with an insurer shall be qualified by education and/or experience which shall include a bachelors degree in criminal justice or a related field, or a bachelors degree and four years of insurance claims investigation experience, or five years of professional investigation experience with law enforcement agencies, or a bachelors degree and seven years of professional investigation experience involving economic or insurance related matters. For the purposes of evaluation of medical related claims insurers may employ or retain duly licensed or authorized medical professionals. Notwithstanding these minimum requirements anyone employed as an investigator in a special investigation unit or by a provider of investigative services under contract to an insurer as of the effective date of this amendment and who was also so employed on or before September 10, 1996 may continue in such employment provided the insurer identifies such person in writing to the superintendent giving the date such employment began and a description of the persons qualifications, employment history and current job duties.|
|(d)||Every insurer required to file a fraud prevention plan shall file an annual report with the Insurance Frauds Bureau no later than January 15 of each year on a form approved by the superintendent, describing the insurers experience, performance and cost effectiveness in implementing the plan and its proposals for modifications to the plan to amend its operations, to improve performance or to remedy observed deficiencies. The report shall be reviewed and signed by an executive officer of the insurer responsible for the operations of the Special Investigations Unit.|
I, Neil D. Levin, Superintendent of Insurance of the State of New York, do hereby certify that the foregoing second amendment to Regulation No. 95 (11 NYCRR 86) was duly adopted by me on this day pursuant to the authority granted by Sections 201, 301, 403 (d) and (e), 409 and 4322 of the Insurance Law.
The Notice of Proposed Rule Making for this amendment was published in the State Register on November 12, 1997, I.D. # INS-45-97-00031-P.
Neil D. Levin
Superintendent of Insurance
May 11, 1998