# COMAR 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

**Administrative History:** Effective date: November 12, 2012 (39:22 Md. R. 1430)

#### Regulation .01 Scope.

*COMAR 31.16.10.01*

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.

#### Regulation .02 Definitions.

*COMAR 31.16.10.02*

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 the Insurance Commissioner of Maryland or the Insurance Commissioner’s designee.

  (4) “Complainant” means a person who files a complaint with the Commissioner.

  (5) Complaint.

    (a) “Complaint” means any written communication received by the Commissioner that expresses dissatisfaction with a carrier.

    (b) “Complaint” includes an oral communication received by the Commissioner, which is subsequently converted to a written form.

    (c) “Complaint” does not include a dispute regarding a claim that is resolved by the Consumer Education and Advocacy Unit through the Rapid Response Program.

    (d) “Complaint” includes a dispute that is initially handled by the Consumer Education and Advocacy Unit that is not resolved and is referred for a complaint investigation.

    (e) “Complaint” does not include actions taken under Insurance Article, §27-1001, Annotated Code of Maryland.

    (f) “Complaint” does not include a dispute that is subject to the authority of the Workers’ Compensation Commission.

  (6) “Complaint investigation” means the process used by the Commissioner to determine if a carrier has violated a State statute, regulation, or order in its dealings or interactions with the complainant, to the extent the Commissioner has the authority to enforce that statute, regulation, or order.

  (7) Determination.

    (a) “Determination” means a decision by the Commissioner that requires the Commissioner to provide the opportunity for a hearing to a person aggrieved by the decision under Insurance Article, §2-210, Annotated Code of Maryland.

    (b) “Determination” includes:

      (i) A decision as to whether a carrier against whom a complaint has been received violated a law, regulation, or order; and

      (ii) An order or notice issued under Insurance Article, §2-204, Annotated Code of Maryland.

  (8) “Health care provider” means:

    (a) A hospital, as defined in Health-General Article, §19-301, Annotated Code of Maryland; or

    (b) A person who is:

      (i) Licensed under Health Occupations Article, Annotated Code of Maryland, or similar laws of another state, to render health care services; and

      (ii) The treating provider of the individual who is entitled to coverage under a contract issued or delivered in Maryland by a carrier.

  (9) “Market conduct action” has the meaning stated in COMAR 31.04.20.03.

  (10) “Person” has the meaning stated in Insurance Article, §1-101, Annotated Code of Maryland.

  (11) “Premium” has the meaning stated in Insurance Article, §1-101, Annotated Code of Maryland.

  (12) “Rapid Response Program” means the process designed by the Administration to help Maryland residents resolve personal property and casualty insurance claims directly with the individual’s insurer.

#### Regulation .03 Complaint investigation.

*COMAR 31.16.10.03*

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 for which the claim was filed, unless otherwise specified.

C. The Commissioner shall acknowledge receipt of the complaint by sending a letter or a copy of the correspondence described in §D of this regulation to the complainant and the carrier.

D. If the Commissioner determines information or documentation is needed from a carrier to conduct a complaint investigation, in accordance with Regulation .06 of this chapter:

  (1) The Commissioner shall request information or documentation; and

  (2) The carrier shall provide the information and documentation by the later of:

    (a) 15 working days after receipt of the Commissioner’s request; or

    (b) The time period specified by the Commissioner in correspondence to the carrier.

#### Regulation .04 Determination.

*COMAR 31.16.10.04*

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 first-class mail or by any other means permitted by law.

#### Regulation .05 Reporting.

*COMAR 31.16.10.05*

The Commissioner shall report data concerning the outcome of the complaint to the National Association of Insurance Commissioners.

#### Regulation .06 Information.

*COMAR 31.16.10.06*

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 and E of this regulation; and

  (2) In the manner specified by the Commissioner.

C. If the carrier does not have the information or documentation requested by the Commissioner under §A of this regulation, the carrier shall provide the reason the carrier does not have the requested information or documentation.

D. Request for Extension of Time to Respond.

  (1) A carrier may submit a written request by first-class mail, facsimile, or electronic mail for an extension of time to respond to a request for information or documentation from the Commissioner.

  (2) The request for an extension shall:

    (a) Specify the reason an extension is needed; and

    (b) Be received by the Commissioner prior to the date the information or documentation was due.

E. Upon receipt of a timely written request for an extension under §D of this regulation, the Commissioner shall:

  (1) Grant an extension and provide the requestor with a new date by which the requested information or documentation is to be provided; or

  (2) Notify the carrier that the request to extend the time is denied.

F. Information related to a complaint investigation is subject to the Public Information Act, State Government Article, Title 10, Subtitle 6, Annotated Code of Maryland.

G. A carrier submitting information to the Commissioner during a complaint investigation may submit a written request that the information not be disclosed under the Public Information Act.

H. A request under §G of this regulation shall:

  (1) Identify the particular information that the carrier requests not be disclosed; and

  (2) Cite the statutory authority that permits denial of access to the information.

I. The Commissioner may review a request made under §G of this regulation upon receipt of a request for access pursuant to the Public Information Act.

J. The Commissioner may notify the carrier who made a request under §G of this regulation before granting access to information that was the subject of the request.

#### Regulation .07 Commissioner’s Actions.

*COMAR 31.16.10.07*

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.

#### Regulation .08 Sanctions.

*COMAR 31.16.10.08*

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.

#### Regulation .09 Hearings.

*COMAR 31.16.10.09*

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.