69J-2.003: Mediation Procedures for Resolution of Disputed Personal Lines Insurance Claims Arising from the 2004 and 2005 Hurricanes and Tropical Storms
PURPOSE AND EFFECT: The proposed rule defines terms used in the rule and in Section 627.7015, F.S., and specifies the information that shall be submitted by an insured in order to initiate mediation. This amendment also makes clerical revisions to the existing rule, and addresses other matters relating to the mediation program governed by the rule.
SUMMARY: Definitions of “claim,” “dispute,” and “filed” are provided and procedures specified to clarify when the duty of an insurer to provide notice to an insured of the right to mediation attaches pursuant to Section 627.7015, F.S. The rule provides that an insurer must provide notice of the right to mediate within 5 business days of receiving a description of a dispute involving material fact regarding an insured’s reported hurricane loss, upon remitting a claim amount less than the lowest estimate submitted by the insured, with a notice of whole or partial denial, or if the insurer has not made a decision within 60 days of being informed about the loss.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS: No Statement of Estimated Regulatory Cost was prepared.
Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.
SPECIFIC AUTHORITY: 624.308 FS.
LAW IMPLEMENTED: 624.307, 627.7015 FS.
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE,TIME AND PLACE SHOWN BELOW(IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):
DATE AND TIME: Thursday, May 8, 2008, 9:30 a.m.
PLACE: 116 Larson Building, 200 East Gaines Street, Tallahassee, Florida
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 5 days before the workshop/meeting by contacting: Tom Valentine, (850)413-4140. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Tom Valentine, Assistant General Counsel, Department of Financial Services 200 East Gaines Street, Tallahassee, Florida 32399, (850)413-4140
THE FULL TEXT OF THE PROPOSED RULE IS:
69J-2.003 Lines Insurance Claims Arising from the 2004 and 2005 Hurricanes and Tropical Storms.
(1) No change.
(2) Definitions. The following definitions apply to the terms of this rule as used herein, and in Section 627.7015,
(a) No change.
(b) “Claim”, as used in subsection (3), below, means a reported hurricane loss involving any material fact on which there is a dispute or for which the insurer has refused payment in whole or in part. Unless the parties agree to mediate a claim involving a lesser amount, a “claim” involves the insured requesting $500 or more to settle the dispute, or the difference between the positions of the parties is $500 or more, in either case, notwithstanding any applicable deductible. “Claim” does not include a dispute with respect to the instances described in Section 627.7015(9), F.S. means any matter on which there is a dispute or for which the insurer has denied payment. Unless the parties agree to mediate a claim involving a lesser amount, a “claim” involves the insured requesting $500 or more to settle the dispute, or the difference between the positions of the parties is $500 or more, in either case, notwithstanding any applicable deductible. “Claim” does not include a dispute with respect to which the insurer has reported allegations of fraud, based on an investigation by the insurer’s special investigative unit, to the Department’s Division of Insurance Fraud.
(c) No change.
(d) “Dispute” means a disagreement involving a material fact between the insurer and the insured regarding the settlement of a hurricane loss, pursuant to Section 627.7015, F.S. “Mediator” means an individual selected by the Department to mediate disputes pursuant to this rule. The mediators will be selected from a panel of circuit court – civil certified mediators approved by the Florida Supreme Court pursuant to the Florida Rules of Certified and Court-Appointed Mediators or from the list of approved mediators pursuant to Rule 69B-166.031, F.A.C.
(e) “Filed” means the insurer has received proper notification of a dispute involving a material fact from the insured or the Department at a location identified by the insurer for hurricane claims reporting. “Party” or “Parties” means the insured and his or her insurer, including Citizens Property Insurance Corporation, when applicable.
(f) “Mediator” means an individual selected by the Department to mediate disputes pursuant to this rule. The mediators will be selected from a panel of circuit court – civil certified mediators approved by the Florida Supreme Court pursuant to the Florida Rules of Certified and Court-Appointed Mediators or from the list of approved mediators pursuant to Rule 69B-166.031, F.A.C.
(g) “Party” or “Parties” means the insured and his or her insurer, including Citizens Property Insurance Corporation, when applicable.
(3) Notification of Right to Mediate; Procedures.
(a) Responsibilities of the Insurer.
1. Upon receiving a verbal or written description of a dispute involving a material fact regarding an insured’s reported hurricane loss, and the information described in subparagraphs (4)(a)1. and 2. below, the insurer shall provide a notification of right to mediate to the insured within five business days.
2. If the insurer has not been notified of a claim as defined herein prior to the time an insurer notifies the insured that a reported hurricane loss has been denied in whole or in part, the insurer shall mail a notice of the right to mediate to the insured in the same mailing as a notice of denial. An insurer is not required to send a notice of the right to mediate if a claim or reported hurricane loss is denied because the amount of the claim is less than the insured’s deductible, based upon the estimate submitted by the insured.
3. If, after accepting the reported hurricane loss, the insurer remits a settlement amount less than the lowest estimate submitted by the insured, the insurer shall enclose a notification of right to mediate to the insured with the remittance.
4. If, after receiving the information described in subparagraphs (4)(a)1. and 2., below, the insurer has not rendered a decision regarding the reported hurricane loss within 60 days, the insurer shall mail a notification of right to mediate to the insured.
5. Regardless of the current status of the insured’s claims file, in all cases where the requirements of subparagraphs (3)(a)1. and 2., above, have not been met and a supplemental claim has been filed, the insurer shall mail a notification of right to mediate to the insured. However, in no event will an insurer be required to send more than one notification for any single claim or supplemental claim. The insurer shall mail notice of the right to mediate disputed claims with in five (5) days of the time the insured or the Department notifies an insurer of a dispute regarding the insured’s claim. If the insurer has not been notified of a disputed claim prior to the time an insurer notifies an insured that a claim has been denied in whole or in part, the insured shall mail a notice of the right to mediate disputed claims to the insured in the same mailing as a notice of denial. An insurer is not required to send a notice of the right to mediate disputed claims if a claim is denied because the amount of the claim is less than the insured’s deductible.
(b) Responsibilities of the Insured.
1. In order to qualify to receive a notice of the right to mediate in those instances where the insurer has not rendered a decision within 60 days on the reported hurricane loss, the insured must provide to the insurer or the Department: a description of the dispute, the name, address, e-mail address, and daytime telephone number of the insured, the location of the property if different from the address given, and the claim and policy number for the insured;
2. In those instances in which the insured has accepted a settlement amount without benefit of a notice of the right to mediate, and the insured should have received such notice by virtue of having triggered the requirements of paragraph (3)(a), above, the insured, after receiving such notice, shall submit a supplemental claim in order to perfect their right to mediation.
(c) Responsibilities of the Department.
1. If the Department is imformed by an insured that a dispute involving a material fact exists with respect to settlement of an insured’s reported hurricane loss, the Department will endeavor to assist the insured in providing and transmitting the information described in subparagraphs (4)(a)1., 2., and 3., below to the insurer.
2. In the event an insurer fails to comply with the requirements of paragraph (3)(a), above, the Department will take administrative action pursuant to Section 624.307, Section 626.9561, and Subsections 626.9571-626.9601, F.S. to achieve insurer compliance with the requirements of this rule.
(d)(b) The mailing that contains the notice of the right to mediate may include the Department’s consumer brochure on mediation but no other materials, forms, or documents may be included. Notification shall be in writing and shall be legible, conspicuous, and printed in at least 12-point type. The first paragraph of the notice shall contain the following statement: “Alex Sink Tom Gallagher, Chief Financial Officer for the State of 1(800)227-8676 (1(800)22-STORM) 1(877)MYFLCFO or (1(877)693-5236).”
(e)(c) The notice shall also:
1. through 4. No change.
(4) Procedures for Requesting Mediation Request for Mediation.
(a) By the Insured. After 21 days from the date of the notice of the right to mediation, an insured may request mediation by contacting the insurer or by calling the Department at 1(877)MYFLCFO or (1(877)693-5236) 1(800)22-STORM (1(800)227-8676); by faxing a request to the Department at (850)488-6372; or by writing to the Department of Financial Services, Mediation Section, Bureau of Education, Advocacy, and Research, Tallahassee, Florida 32399-4212. Alternatively, an insured may request mediation prior to receipt of the notice of the right to mediation if they meet certain requirements. If an insured requests mediation prior to receipt of the notice of the right to mediation or if the date of the notice cannot be established, the insurer shall be notified by the Department of the existence of the dispute 21 days prior to the Administrator processing the insured’s request for mediation. Upon such request, in order to be scheduled for mediation, the insured shall should provide the following information if known:
1. The nName, address, e-mail address, and daytime telephone number of the insured and location of the property if different from the address given;
2. through 5. No change.
If an insurer receives a request for mediation, the insurer shall fax the request to the Department’s Mediation Section within 48 hours of receipt of the request. The Department will forward requests to the Administrator within 24 hours of receipt of the request. The Administrator shall notify the insurer within 48 hours of receipt of requests filed with the Department. In instances where the insured has requested mediation prior to receiving a notice of the right to mediation, and has provided the information described above, upon notification, the Administrator shall process the request for mediation no less than 21 days thereafter.
(b) No change.
(5) through (14) No change.
Specific Authority 624.308, 626.9611, 627.7015(4) FS. Law Implemented 624.307(1), (2), (4), (5), 624.317, 624.318, 624.324, 626.859, 626.874, 626.877, 626.9541(1)(a), (e), (i), (u), 626.9561, 626.9641(1)(g), 627.7015 FS. History–New 7-26-06, Amended________.