CLAIMS GUIDELINES

 

1. GENERAL CLAIMS RESPONSIBILITIES

Each member is responsible for:

— the proper disposition of Bodily Injury Liability claims in accordance with the applicable tort limitation option elected by the claimant;

— the proper verification of the claimant's alleged election of the $0 tort limitation option in all claims falling within the "reportable" claim definition, including adequate file documentation thereof;

— the maintenance of accurate records identifying those paid claims which qualify as "reportable" claims as defined by the appropriate Reportable Claim Determination Form;

— the reporting of Bodily Injury claims, and "reportable" claim loss and claim expense data, in response to the quarterly statistical calls made by the Risk Exchange Board of Directors;

— making available for review by duly authorized Audit or Claim Committee personnel, the claim files and related records pertaining to all Bodily Injury claim settlements.

The determination whether Bodily Injury liability claim payment qualifies as a "reportable" claim must be made at the time the claim is settled; such determination shall be based on facts that are known or can reasonably be anticipated at the time of settlement.

The determination that a Bodily Injury liability claim qualifies as a "reportable" claim may be subsequently changed by order of the A.I.R.E. Board of Directors acting upon the findings and recommendations of its Claims or Audit Committee that the decision was clearly not consistent with facts known or reasonably anticipated at the time of the claim settlement.

The fact that the claim representative is required to make the determination that a particular claim as of date of settlement qualifies as a "reportable" claim shall in no way affect nor in any way modify the standards applicable in investigation, evaluation, timeless and manner of negotiation and disposition of the claim.

 

2. THRESHOLD VERIFICATION GUIDELINES

a) When the third party Bodily Injury liability claimant alleges the election of the $0 tort limitation, and the nature of the injury is such that the monetary threshold is required to determine if the claim is a "reportable" claim, the allegation of the $0 tort threshold must be verified via one of the following methods:
  1. require the claimant to produce valid policy documentation which confirms the fact that the $0 tort threshold was elected and was still in force on accident date, or;
  2. utilize the reporting facilities of ISO ClaimSearch via procedures described in Subsection (b), hereunder, or;
  3. obtain written verification from the member liability insurer of the third party claimant confirming the election of the $0 tort threshold, or;
  4. obtain telephone verification from the member insurer or the insurance agent of the third party claimant confirming the election of the $0 tort threshold. When utilizing the telephone verification method, the claim file must contain the telephone number called and the identity of the party providing the information, and the date such telephone verification was obtained.

5) obtain documentation that the claimant had no insurance. This may be in the form of an

affidavit, statement of damages, bill of particulars in litigation or written statement from the

claimant explaining that they have no available insurance coverage.

b) Use of ClaimSearch For Verification -

1) In order to ensure a single available source for use by all members to verify the alleged election by a third party bodily injury liability claimant of the $0 tort threshold, all members may comply with the following ClaimSearch Report requirements using the universal format:

— Report all New Jersey Personal Injury Protection (PIP) claims to ISO ClaimSearch as soon as possible after the PIP claim is made.

— In addition to the requested information, the PIP Insurer submitting the report shall the tort threshold elected by the named insured(s) under whose policy the PIP claimant is entitled to recover his/her PIP benefits by answering the following two items for New Jersey insureds:

Tort Threshold Type: O Verbal O Dollar

Tort Threshold State: [ ]

2) ISO ClaimSearch, upon receipt of the report prepared by the member Liability Insurer reporting the required information on the third party bodily injury liability claimant, will "match" said report to the report submitted by the member PIP Insurer, involving the same injured person. The tort threshold reported by the member PIP Insurer will serve to confirm the applicable tort limitation.

3) Members should promptly submit the required reports (B.I. Liability and PIP claims) to the ClaimSearch system in order to ensure the workability of the described tort threshold verification procedure.

c) Use of Written and/or Telephone Verification Procedures

To facilitate the necessary exchange of information between members for the purpose of verifying the alleged election of the $0 tort threshold by a third party bodily injury liability claimant, each member shall be required to report the following information to the Exchange:

The name, mailing address(es) and telephone number(s) of the member insurer to which other member insurers may direct written and/or telephone requests for threshold verification.

The Exchange shall, upon receipt of the above information, publish a single directory containing the current names, addresses and telephone numbers of all members, and shall deliver a copy of such directory to all members. Changes to address or telephone listings shall be reported by members to the Exchange. The Exchange shall periodically publish and send to all members addendum updates to the directory. Each member shall be required to furnish all its claim offices with copies of the directory and addendum updates.

 

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