NAIC Unfair Life, Accident and Health Claims Settlement Practices Model Regulation (#903)

What this document is

NAIC Unfair Life, Accident and Health Claims Settlement Practices Model Regulation (#903) is a naic model law published by National Association of Insurance Commissioners (NAIC). It is one of the documents that insurance license exam questions are written from, including life & health practice questions. This page summarizes it and points to the official version, which is the text to rely on.

Sections cited in practice questions

Each practice answer shows the exact passage it comes from. These are sections of this document that questions cite, with a short excerpt from the source text.

• NAIC Unfair Life, Accident and Health Claims Settlement Practices Model Regulation (#903), Section 4D

  “D. The insurer shall affirm or deny liability on claims within a reasonable time and shall offer payment within thirty (30) days of affirmation of liability if the amount of the claim is determined and not in dispute. If portions of the claim are in dispute, the insurer shall tender payment for...”

• NAIC Unfair Life, Accident and Health Claims Settlement Practices Model Regulation (#903), Section 5A

  “A. The insurer shall maintain claim data that are accessible and retrievable for examination. An insurer shall be able to provide the claim number, line of coverage, date of loss and date of payment of the claim, date of denial or date closed without payment. This data shall be available for all...”

• NAIC Unfair Life, Accident and Health Claims Settlement Practices Model Regulation (#903), Section 4G

  “G. If a claim remains unresolved for thirty (30) days from the date proof of loss is received, the insurer shall provide the insured or, when applicable, the insured’s beneficiary, with a reasonable written explanation for the delay. In credit, mortgage and assigned accident/health claims, the...”

• NAIC Unfair Life, Accident and Health Claims Settlement Practices Model Regulation (#903), Section 4J

  “J. No insurer shall deny a claim upon information obtained in a telephone conversation or personal interview with any source unless the telephone conversation or personal interview is documented in the claim file.”

• NAIC Unfair Life, Accident and Health Claims Settlement Practices Model Regulation (#903), Section 4L

  “L. No insurer shall indicate to a first party claimant on a payment draft, check or in any accompanying letter that said payment is “final” or “a release” of any claim unless the policy limit has been paid or there has been a compromise settlement agreed to by the first party claimant and the...”

• NAIC Unfair Life, Accident and Health Claims Settlement Practices Model Regulation (#903), Section 4A

  “A. Every insurer, upon receiving due notification of a claim shall, within fifteen (15) days of the notification, provide necessary claim forms, instructions and reasonable assistance so the insured can properly comply with company requirements for filing a claim.”

• NAIC Unfair Life, Accident and Health Claims Settlement Practices Model Regulation (#903), Section 4I

  “I. When a claim is denied, written notice of denial shall be sent to the claimant within fifteen (15) days of the determination. The insurer shall reference the policy provision, condition or exclusion upon which the denial is based.”

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