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Upon receiving notice of claim, the insured may choose to receive documents by mail with a return receipt, acknowledgment from the recipient, a secure website posting, or through a personal device application secured by a password or biometric security. If a record has not been successfully delivered to the recipient's email address, the insurer must resend the record to the recipient's email address, or by 1 of the other authorized methods, within 5 business days after receiving notice that the delivery was unsuccessful.
The purpose of the California Life and Health Insurance Guarantee Association (CLHIGA) is to protect policyowners, insureds, beneficiaries, and payees against losses that might otherwise occur due to the impairment or insolvency of a life or health insurer. (CIC 1067.02(a)1)
CLHIGA covers most life insurance, health insurance, and annuity contracts issued to state residents (and, in special circumstances, to nonresidents), including structured settlement annuities. (CIC 1067.02(b)1)
CLHIGA maintains a life insurance and annuity account (with 2 subaccounts) and a health insurance account. Member insurers may be assessed up to 1% of their annual premium per year to fund the Association's obligations.
CIC 790-790.10 gives the Commissioner exclusive authority to enforce prohibitions against unfair trade practices in the business of insurance.
No person may engage in this state in any trade practice defined as an unfair method of competition or an unfair or deceptive act or practice, including misrepresenting the benefits, advantages, conditions, or terms of any policy.
Knowingly committing or performing any of the following with such frequency as to indicate a general business practice constitutes an unfair claims settlement practice:
Additional prohibited practices include attempting to coerce arbitration appeals; requiring duplicate preliminary and formal claim reports; discouraging claimants from consulting an attorney; delaying payment of claims involving AIDS beyond 60 days without a good faith basis (unless the delay is due to awaiting a response from a health care provider); filing false financial statements; unfairly discriminating; falsely advertising CLHIGA membership; and boycott, coercion, or intimidation.
Before issuing a cease and desist order, the Commissioner must give the accused notice and an opportunity for a hearing within 30 days.
| Violation | Penalty |
|---|---|
| Unfair trade practice (per act) | Up to $5,000 |
| Willful violation, or general business practice (per act) | Up to $10,000 |
| Violation of a cease and desist order | Up to $5,000 |
| Willful violation of a cease and desist order | Up to $55,000 |
These penalties are cumulative to any other penalty provided elsewhere in the Insurance Code.
CIC 10140-10145 distinguishes fair discrimination — underwriting decisions justified by sound actuarial principles or actual/reasonably anticipated claims experience — from unfair discrimination, which is illegal.
Acceptable rating factors include gender, age, tobacco use, height/weight ratio, geographic location, and profession or avocations, but these may only be combined when statistically justified for the specific type of coverage. For example, using ZIP code to price life insurance is unacceptable, while using ZIP code to price health insurance is acceptable, since regional healthcare costs vary significantly.
Clients who fall within the same actuarial classification must receive identical rates, premiums, and benefits.
The following characteristics may never be used to classify or rate an applicant, because they have no effect on risk: race, color, religion, national origin, ancestry, sexual orientation, and physical or mental impairments (including blindness or other vision impairment) which do not increase risk. It is acceptable to ask an applicant's place of birth only for identification purposes.
In regard to sexual orientation, it would be a blatant violation for an insurer to ask an applicant any question regarding the subject. It has been noticed, however, that an insurer may attempt to reach a conclusion about sexual orientation through other factors and then adjust benefits or premium based on a presumption of increased AIDS risk. Insurers therefore may not use any of the following to make a judgment about sexual orientation:
An insurer concerned about AIDS-related claims risk that wishes to test for HIV must test every applicant under the same guidelines.
If an insured with a condition expected to cause death within 1 year requests an experimental treatment and is refused, the insurer must provide the specific medical and scientific reasons for the denial with references to the pertinent policy provisions, a description of any alternative medical procedures covered by the policy, and a description of the appeal/review process, which must take no more than 30 days (or 5 days if delaying treatment would be detrimental).
Insurers providing life or health insurance may not do anything affecting coverage or premium because they suspect an applicant may become a victim of domestic violence, even if the applicant was a victim in the past — although underwriters may still consider an actual medical condition, as long as they do not consider whether it was caused by domestic violence. Intentional acts of the insured can still result in loss of benefits. Domestic violence is defined by Section 6211 of the California Family Code as abuse perpetrated against a spouse or former spouse; a cohabitant or former cohabitant; a person with whom the respondent is having or has had a dating or engagement relationship; a person with whom the respondent has had a child; a child of a party to such an action; or any other person related by blood or affinity within the second degree.
Medical policies must include coverage for diagnosing and treating severe mental illness and serious emotional disturbances of a child the same as they do any other condition. This requirement does not apply to policies that cover specific conditions only, such as accident only, hospital indemnity, vision only, or dental only.
In addition to any other remedy permitted by law, the Commissioner has administrative authority to assess penalties against life or disability insurers for unfair discrimination violations:
| Violation | Penalty |
|---|---|
| 1st violation | $2,500 |
| Subsequent violations | $5,000 each |
| Violations frequent enough to indicate a general business practice | $15,000 – $100,000 per violation |
Any person who negligently discloses the results of a genetic test to an unauthorized third party is subject to a civil penalty of up to $1,000 plus court costs, payable to the subject of the test; a willful violation carries a civil penalty of $1,000 to $5,000 plus court costs. If the subject suffers economic, bodily, or emotional harm, the violation becomes a misdemeanor punishable by a fine of up to $10,000, with each unauthorized disclosure a separate violation.
Insurance fraud is a significant problem for insurance companies and insureds alike; premiums for most forms of insurance have risen because of the increasing number of fraudulent claims presented for payment. Common forms of insurance fraud include staged automobile accidents, fraudulent healthcare billings (including HMO and Medi-Cal), false or inflated property loss claims, phony workers' compensation claims, fraudulent denial of workers' compensation benefits, arson for profit, fake life insurance claims, and workers' compensation premium fraud by employers.
Federal, state, and local law enforcement officials work together, aided by insurance companies and industry support organizations, to combat all forms of insurance fraud. The California Department of Insurance has created the Fraud Division to enforce the provisions of the Penal Code and administer fraud reporting requirements. (CIC 1872)
The Arson Information Reporting System allows cooperation between insurers, law enforcement agencies, fire investigating agencies, and district attorneys. The State Fire Marshal oversees the establishment, operation, and maintenance of the System, which allows all parties to deposit arson case information into a common database within the Department of Justice. Information in the System cannot become part of the public record; any authorized governmental agency, insurer, or agent authorized to act on an insurer's behalf that receives such information may not release it to public inspection until its release is required in connection with a criminal or civil proceeding. (CIC 1875.8)
Insurance companies, agents, and brokers have a legal responsibility to report suspected fraud. Whenever an insurer or licensed rating organization knows or reasonably believes it knows the identity of a person or entity that has committed a fraudulent act relating to a workers' compensation claim or policy, it must notify the local district attorney's office and the Fraud Division, and may notify any other authorized governmental agency, stating the basis of the suspected fraud. An insurer that believes or knows a fraudulent claim is being made has 60 days to send the Fraud Division the information requested by the department's form, plus any additional information relative to the factual circumstances of the claim and the parties claiming loss or damages. (CIC 1877.3)
The Commissioner may license a nonprofit corporation organized for fraud-prevention purposes with at least 2 years of relevant experience as an Insurance Claims Analysis Bureau. Such a Bureau is required to collect and compile claims-related information and data from members; disseminate that information to members to prevent and suppress insurance fraud; promote training and education related to the investigation, suppression, and prosecution of insurance fraud; and provide the Commissioner, without fee or charge, all state data and information in its records to further prevent and prosecute insurance fraud.
Every insurer admitted to do business in California must provide for the continuous operation of a unit or division to investigate possible fraudulent claims by insureds or by persons making claims for services or repairs against policies held by insureds. (CIC 1875.20)
Insurers, agents, and brokers have legal immunity from civil suits claiming libel or slander that might result from giving statements, filing reports, or furnishing information, as long as it is offered in good faith and without malice.
An agent or broker who, before placing an insurance application with an insurer, reasonably suspects or knows that a fraudulent application is being made must submit the information on an electronic form to the Fraud Division within 60 days after determining that the application may be fraudulent. All data fields within the Fraud Division's Consumer Fraud Reporting Portal electronic form must be completed accurately to the best of the agent's or broker's ability, and a fraud referral may not be submitted anonymously. The Fraud Division will review each report and undertake whatever further investigation it deems necessary to determine the validity of the allegations.
An insurer that reproduces, prints, or furnishes a form on which a person applies for a policy, seeks to amend coverage, furnishes underwriting information affecting premium or eligibility, gives notice of a claim, or makes a claim, must have the following statement printed or displayed prominently on the form: "Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison."
For any claim arising from the theft of an insured vehicle, the claim form must contain a warning that false representations made on the signed claim form by the insured are subject to a penalty of perjury, and the claim form must be signed under penalty of perjury.
Chapter 12 of the Insurance Code is devoted exclusively to the Insurance Fraud Prevention Act, which describes the basic responsibilities of the Insurance Commissioner, law enforcement agencies, insurers, agents, brokers, and others when "confronting aggressively the problem of insurance fraud in this state."
State insurance claim forms are required to carry a notice informing claimants of their liability in the event of a fraudulent claim: "For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison."
Every person who commits insurance fraud may be punished by imprisonment in the county jail for 1 year, or in state prison for up to 5 years; a fine of up to $150,000 or double the value of the fraud, whichever is greater; or both imprisonment and fine. The court determines the amount of restitution and where it must be paid, and a person convicted may be charged for the costs of investigation at the court's discretion. A person who commits insurance fraud and has a prior felony conviction receives a 2-year sentence enhancement for each prior conviction, in addition to the sentence provided.