Annual Special Investigations Unit (SIU) Report

Instructions for Annual SIU Report Submitter

1a & 1b: Policy Count & Premiums Written

Report policy count, or, for group policies, report the number of individuals insured.  Report the corresponding written premium.  Assigned risk should be included.   Include only insured business.

2a & 2b: Number of Claims Processed & Dollar amount of Claims Paid - Only include insured business.

2a Report the number of all claims paid or in the process of payment or denial and include all claims received (entered into the claims system).

2b Report the dollar amount of claims paid.

3a & 3b, Number of Suspicious Claims Detected, Dollar amount of Suspicious Claims Detected

3a Report claims identified as suspicious in the claims settlement process

3b Report the corresponding dollar value of claims identified as suspicious in the claims settlement process

3c & 3d: Number of Investigated Claims Closed and Not Paid, Number of Investigated Claims Partially Paid

3c Report the number of claims reviewed by the SIU that have been denied or closed as a result of investigation

3d Report the number of claims reviewed by the SIU that were partially paid as a result of investigation

4a: Report the total number of referrals, reviewed by the SIU, received from all sources

4b & 4c: Number of Cases Opened by SIU, Number of Cases Closed by SIU

4b Report the number of cases opened by SIU

4c Report the number of cases closed by SIU

4d & 4e Dollar Value of Saving, Dollar Value of Recoveries and Restitution

4d Report the amount of monies not paid during the calendar year due to investigation of suspect claims (or other transactions)

4e Report the amount of monies collected or recovered during the previous calendar year from all sources, including court disposition, resulting from investigations

5 Number of IFBs filed with the Department’s Criminal Investigations Unit

6a & 6b Total Cost of SIU,  Number of Investigators

6aI Report the total cost of New York’s portion of the SIU, on all lines of business, incurred from the insurer's internal investigations (Report in total column)

6aC Report the total cost of New York’s portion of the SIU, for all lines of business, incurred by SIU contractors (Report in total column)

6bI Report Investigator resources (as FTEs) dedicated to investigations related to all lines of business incurred by the Insurer’s employee investigators (I). Insurers using affiliated SIUs should report data in the Insurer (I) column.

6bC Report Investigator resources (as FTEs) incurred by third party contractor investigators for all lines of business

For national and regional SIUs: New York investigator personnel and SIU expenses must be apportioned and reported to reflect New York resources utilized during the previous calendar year.  The amount apportioned must be determined using an allocation methodology detailed in service agreements, or by other reasonable expense allocation method using SIU activity. The number of investigators reported should reflect New York resources dedicated to New York cases and the total investigators must be reported as Full Time Equivalent Investigators (FTEs).  Note that the amounts reported as investigator resources may be reported as a number including two (2) digits after the decimal place to account for the apportioned resources.

Please respond to eight questions below the grid:

  1. How many referrals were made to law enforcement agencies including prosecutors (other than the DFS Criminal Investigations Unit)?
  2. How many civil actions involving suspect transactions were initiated in the previous calendar year?  Include lawsuits initiated to recover amounts paid on investigated cases.
  3. What were the total expenses (allocated and direct) of the public awareness program?  Report direct expenses incurred and /or expenses allocated to the insurer for the public awareness program.
  4. What is the dollar amount of claims adjudicated for self-funded groups? Report the number of claims paid on behalf of self-funded groups.
  5. How many claims were paid on behalf of self-funded groups?
  6. How many IFBs were reported to the NYSDFS on all other lines of business not included above? Report the number of IFBs reported to NYSDFS on all other lines of business not shown in the grid above such as life, annuity, title, homeowners etc.
  7. Where is the SIU located?  Provide the city and state of the primary location of the SIU.
  8. What is the percentage of investigators’ time spent in New York State working on New York State cases?  Report the amount of time all investigators dedicated to New York cases while working in New York, as a percentage of the amount reported in 6b.  If investigators are located in New York but, spent half of their time working on out of state cases, the percentage to report would be 50%.  Enter the amount as a number followed by the percent symbol.  Report the amount of time as a number followed by two (2) decimal places if the amount of time includes a fraction of a fulltime equivalent investigator.

Instructions for Approvers: SIU Manager and Company Executive

An SIU Manager and an Executive officer of the insurer responsible for the operations of the Special Investigations Unit must sign off on the Annual SIU Report after it has been submitted.

Each user with the Manager and Executive portal roles will receive an email notification alerting them that an Annual SIU Report has been submitted and is ready for their review.  The SIU Manager and Executive must each sign into the portal, access the Annual SIU Report application and go to the Review/Approve tab.  There, the user can click the Review button to view the data that was submitted, and the Approve button to approve the submission.