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31.16.10.00.htm 31.16.10.00. Title 31 MARYLAND INSURANCE ADMINISTRATION Subtitle 16 MISCELLANEOUS Chapter 10 Complaint Investigation and Determination Process Authority: Insurance Article, §2-109(a) Health-General Article, §19-705(a)2) Annotated Code of Maryland
31.16.10.01.htm 31.16.10.01. 01 Scope.. A. This chapter applies to carriers that issue or deliver insurance policies or health maintenance organization contracts in Maryland.B. This chapter does not apply to complaints filed under Insurance Article, Title 15, Subtitle 10A, Annotated Code of Maryland.
31.16.10.02.htm 31.16.10.02. 02 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) “Administration” has the meaning stated in Insurance Article, §1-101, Annotated Code of Maryland.. 2) “Carrier” means:. a) An insurer;. b) A nonprofit health service plan;. c) A dental plan organization;. d) A fraternal benefit society;. e) A health maintenance organization; or. f) The Maryland Automobile Insurance Fund (MAIF). 3) “Commissioner” means t
31.16.10.03.htm 31.16.10.03. 03 Complaint investigation.. A. Upon receipt of a complaint, the Commissioner shall begin a complaint investigation.. B. A complaint filed by a health care provider concerning a specific claim under a contract issued or delivered in Maryland by a life insurer, health insurer, nonprofit health service plan, dental plan organization, or health maintenance organization shall be considered to be filed on behalf of the individual who received the health care services f
31.16.10.04.htm 31.16.10.04. 04 Determination.. A. Upon completion of the complaint investigation, the Commissioner shall document the findings of the complaint investigation in a determination letter and, if applicable, an order.B. The documented findings of §A of this regulation shall be provided to the complainant and the carrier that was the subject of the complaint.C. The Commissioner may send the determination letter and, if applicable, the order to the complainant or the carrier by firs
31.16.10.05.htm 31.16.10.05. 05 Reporting.. The Commissioner shall report data concerning the outcome of the complaint to the National Association of Insurance Commissioners.
31.16.10.06.htm 31.16.10.06. 06 Information.. A. The Commissioner may request accounts, records, documents, files, logs, photographs, or other information necessary to complete a complaint investigation.B. Whenever a carrier receives a request from the Commissioner for information and documentation, the carrier shall provide the requested information and documentation:1) On the date specified by the Commissioner, unless an extension has been granted by the Commissioner in accordance with §D
31.16.10.07.htm 31.16.10.07. 07 Commissioner’s Actions.. Based on the information or documentation reviewed during a complaint investigation, the Commissioner may, in the Commissioner’s sole discretion, take one or more of the following actions in addition to issuing a determination letter or, if applicable, an order:A. Initiate a market conduct action in accordance with COMAR 31.04.20; or. B. Take any other action authorized by State law..
31.16.10.08.htm 31.16.10.08. 08 Sanctions.. If a carrier subject to this chapter fails to provide the information or documentation requested by the Commissioner in accordance with this chapter, the carrier may be subject to an administrative penalty not to exceed $500 per day, in addition to any other sanctions available to the Commissioner.
31.16.10.09.htm 31.16.10.09. 09 Hearings.. A person aggrieved by the determination of the Commissioner’s complaint investigation may request a hearing in accordance with the provisions of Insurance Article, §2-210(c) Annotated Code of Maryland, and COMAR 31.02.01.
31.16.10.9999.htm 31.16.10.9999. Administrative History Effective date: November 12, 2012 (39:22 Md. R. 1430).
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