<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".05" citation="COMAR 31.04.15.05" title_num="31" subtitle_num="04" chapter_num="15" heading="Plan Components.">
  <paragraph num="A.">
    <text>Education/Training.</text>
    <paragraph num="(1)">
      <text>An antifraud plan shall contain procedures for the provision of education or training, or both, to the insurer's employees regarding the detection of insurance fraud.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Training in the recognition and referral of suspicious claims shall be:</text>
      <paragraph num="(a)">
        <text>Required of new and existing claims personnel, underwriters, auditors, insurance producers, and consumer service personnel; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Offered to independent insurance producers who have appointments with the company.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(3)">
      <text>At a minimum, the educational components of antifraud plans shall address the following:</text>
      <paragraph num="(a)">
        <text>Courses of instruction shall be:</text>
        <paragraph num="(i)">
          <text>Designed to address specific aspects of fraud associated with a company's product line, and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>At least 2 hours in duration;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>Personnel shall be presented with updated material at the entrance level and at least once every 2 years in conjunction with continuing education standards or as a company policy;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>A new employee shall receive the regulated education and training regarding the detection of fraud within 6 months of the effective date of employment; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Training programs may be developed and conducted either by internal personnel or by outside contractors.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Detection.</text>
    <paragraph num="(1)">
      <text>An antifraud plan shall have provisions regarding the early detection of all areas of fraud including, but not limited to:</text>
      <paragraph num="(a)">
        <text>Embezzlement and internal theft;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Underwriting and application fraud;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Theft and misappropriation of premiums by insurance producers;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Claims fraud; and</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Application fraud.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>The antifraud plan shall delineate the methods or approaches, or both, that will be utilized in detecting fraud.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>An authorized insurer shall:</text>
      <paragraph num="(a)">
        <text>Designate an individual or individuals, or a specific unit, either in-house or outside, to be responsible for coordinating the detection, referral, and investigation of suspected fraudulent activity;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Include the designation in the antifraud plan; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Submit amendments to the designation to the Administration.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(4)">
      <text>Fraud detection guides shall be prepared, published, and maintained to assist claims personnel, underwriters, and insurance producers in the identification, detection, and handling of suspicious claims.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Investigation.</text>
    <paragraph num="(1)">
      <text>An antifraud plan shall contain:</text>
      <paragraph num="(a)">
        <text>Procedures for handling fraud complaints;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Procedures that are to be followed when instances of suspected fraud have been detected, evaluated, and found to warrant a full investigation;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>The requirement that the company representative responsible for the conduct and oversight of fraud investigations assign the matter for investigation;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>The designation of the individuals responsible for conducting investigations on behalf of the insurer including the individuals responsible for providing the notifications required by §C(1)(g) of this regulation;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Guidelines and procedures for conducting investigations and cooperating with the Insurance Fraud Division or other law enforcement agency which is conducting a criminal investigation if in-house staff is utilized;</text>
      </paragraph>
      <paragraph num="(f)">
        <text>Written considerations as to work product and courtroom testimony; and</text>
      </paragraph>
      <paragraph num="(g)">
        <text>Guidelines and procedures for notifying the appropriate law enforcement agency, including the Insurance Fraud Division of the Administration.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Investigators.</text>
      <paragraph num="(a)">
        <text>A company may maintain an in-house staff of investigators or contract with an outside firm.</text>
      </paragraph>
      <paragraph num="(b)">
        <text>If an outside firm is used, the firm shall comply with all Maryland licensing laws and regulations to the extent that they are applicable.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="D.">
    <text>Auditing.</text>
    <paragraph num="(1)">
      <text>An antifraud plan shall contain procedures regarding the auditing of insurance producers by the company.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The auditing procedures shall provide for both routine auditing and random audits.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>If an irregularity is discovered during an audit, the antifraud plan shall require that the duly authorized company representative who conducts or oversees investigations be notified immediately.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>Referral for Prosecution.</text>
    <paragraph num="(1)">
      <text>If an insurer, in good faith, has cause to believe that insurance fraud has been or is being committed, the insurer shall report the suspected fraud to the Insurance Fraud Division or to the appropriate federal, State, or local law enforcement authority.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The reporting policy shall be in writing and maintained in the offices of the company point of contact for fraud.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>The written policy shall be open for inspection by market conduct examiners of the Maryland Insurance Administration.</text>
    </paragraph>
  </paragraph>
</regulation>