Section 2274.52 - The Proper Complaint(a) Subject to the additional requirements applicable to the complaint that are set forth in subdivisions (c) and (e) of this Section 2274.52, a request for review received by the commissioner from a policyholder, certificate holder or other insured constitutes a proper complaint for purposes of subdivision (b) of Insurance Code section 10273.7 if the complainant asserts, with or without prompting by the Department, all of the following:(1) The insurance product in question constitutes health insurance that is within the jurisdiction of the Department of Insurance;(2) The complainant has not voluntarily terminated the policy or coverage; and(3) The complainant has been notified in writing, or has otherwise learned, that its policy, certificate or coverage has been or will be canceled, rescinded or nonrenewed by the insurer.(b) After receiving a request for review, the Department shall contact the insurer in question, notify it of the policyholder's, certificate holder's or other insured's request for review, including the date thereof, and request from the insurer any information that may help the Department to determine whether the insurance coverage in question constitutes health insurance that is within the jurisdiction of the Department of Insurance. The preceding sentence shall not be binding on the Department, however, if the Department has not received: (1) The name of the policyholder, certificate holder or other insured,(2) The applicable policy number, certificate number or claim number, and(3) The name of the insurer.(c) In the event the Department establishes that the insurance coverage in question is not within its jurisdiction, the request for review shall not constitute a proper complaint.(d) As soon as practicable after the date the Department receives a request for review, but no later than 30 days after the date the Department contacts the insurer pursuant to subdivision (b) of this Section 2274.52, the Department shall send notice to the insurer in question identifying the policyholder, certificate holder or other insured that has made the request for review. The 30-day deadline stated in the immediately preceding sentence shall not apply, however, if the insurer fails to make reasonable efforts to promptly provide the Department with the information requested by the Department pursuant to subdivision (b). The notice shall indicate either that the commissioner has determined that a proper complaint exists or that not all of the requirements applicable to the complaint that are set forth in this Section 2274.52 were satisfied.(e) The request for review shall not constitute a proper complaint if the Department has not received: (1) The name of the policyholder, certificate holder or other insured,(2) The applicable policy number, certificate number or claim number, and(3) The name of the insurer.(f) Review by the commissioner pursuant to Insurance Code Section 10273.7 shall be in addition to, and not in lieu of, any internal or external review process the insurer is required to offer or perform pursuant to any other provision of law or pursuant to the terms of any order of the commissioner binding on the insurer.Cal. Code Regs. Tit. 10, § 2274.52
1. New section filed 11-20-2013; operative 1-1-2014 (Register 2013, No. 47). Note: Authority cited: Sections 10273.7 and 12926, Insurance Code; CalFarm Ins. Co. v. Deukmejian, 48 Cal.3d 805 (1989) and 20th Century Ins. Co. v. Garamendi, 8 Cal. 4th 216 (1994). Reference: Sections 10273.4, 10273.6, 10273.7, 10384, 10384.17 and 10713, Insurance Code.
1. New section filed 11-20-2013; operative 1-1-2014 (Register 2013, No. 47).