Definitions

PURPOSE: This rule sets forth definitions used in the rules in this division to aid in the interpretation of various terms and phrases. (1) As used in the Unfair Claims Settlement Practices Act at sections 375.1000 to 375.1018, RSMo and in the regulations promulgated pursuant thereto— (A) “Insurance producer” or “producer,” any individual, corporation, association, partnership, or other legal entity authorized to represent an insurer with respect to a claim; (B) “Claim,”— 1. A request or demand for payment of a loss which may be included within the terms of coverage of an insurance policy; or 2. A request or demand for any other payment under the policy, such as for the return of unearned premium or nonforfeiture benefits; (C) “Claimant,” any— 1. First-party claimant, including a subscriber under any plan providing health services; 2. Third-party claimant; or 3. Person or entity submitting a claim on behalf of any insured and includes the claimant’s designated legal representative and a member of the claimant’s immediate family designated by the claimant; (D) “First-party claimant,” any individual, corporation, association, partnership, or other legal entity asserting a right to payment arising out of the occurrence of a contingency or loss covered by an insurance policy; (E) “Insurer,” has the same meaning as in section 375.1002(2), RSMo; (F) “Investigation,” all activities of an insurer directly or indirectly related to the determination of liabilities under coverages afforded by an insurance policy; (G) “Notification of claim,” any notification, whether in writing or by other means acceptable under the terms of an insurance policy to an insurer or its insurance producer, by a claimant, which reasonably apprises the insurer of the facts pertinent to a claim; (H) “Third-party claimant,” any individual, corporation, association, partnership or other legal entity asserting a claim against any individual, corporation, association, partnership, or other legal entity insured under an insurance policy; (I) “Insurance policy,” any insurance contract, certificate of insurance or contract under which health services are to be provided; and (J) “Time error rate,” refers to any one (1) of the following: 1. Acknowledgment time error rate, the percentage of claims in which the insurer has performed an act described in section 375.1007(2), RSMo, or violated 20 CSR 100-1.030; 2. Investigation time error rate, the percentage of claims in which the insurer has performed an act described in section 375.1007(3), RSMo, or violated 20 CSR 100-1.030; or 3. Determination time error rate, the percentage of claims in which the insurer has performed an act described in section 375.1007(7), RSMo, or violated 20 CSR 100-1.050. AUTHORITY: sections 374.045 and 375.1000–375.1018, RSMo 2016.* This rule was previously filed as 4 CSR 190-10.060(1). Original rule filed Aug. 5, 1974, effective Aug. 15, 1974. Rescinded and readopted: Filed Aug. 16, 1978, effective Dec. 11, 1978. Amended: Filed Sept. 11, 1980, effective Feb. 16, 1981. Amended: Filed Sept. 14, 1981, effective Jan. 15, 1982. Amended: Filed Aug. 4, 1986, effective Jan. 1, 1987. Amended: Filed Jan. 5, 1987, effective June 1, 1987. Amended: Filed Aug. 4, 1987, effective Dec. 24, 1987. Amended: Filed Dec. 9, 1988, effective April 28, 1989. Amended: Filed Nov. 2, 1989, effective Feb. 15, 1990. Emergency amendment filed Feb. 21, 1990, effective March 5, 1990, expired June 2, 1990. Amended: Filed Feb. 26, 1990, effective June 11, 1990. Amended: Filed Dec. 12, 1990, effective June 10, 1991. Amended: Filed Oct. 1, 1996, effective June 30, 1997. Amended: Filed Dec. 1, 1998, effective July 30, 1999. Amended: Filed July 12, 2002, effective Jan. 30, 2003. Amended: Filed Nov. 1, 2007, effective July 30, 2008. Amended: Filed Dec. 13, 2018, effective July 30, 2019. *Original authority: 374.045, RSMo 1967, amended 1993, 1995, 2008 and 375.1000–375.1018, see RSMo 2016.