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Virginia Administrative Code
Title 14. Insurance
Agency 5. State Corporation Commission, Bureau of Insurance
Chapter 400. Rules Governing Unfair Claim Settlement Practices
9/21/2020

14VAC5-400-20. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Agent" means any person authorized to represent an insurer with respect to a claim.

"Claim" means a demand for payment by a claimant and does not mean an inquiry concerning coverage.

"Claimant" means a first party claimant, a third party claimant, a designated legal representative, or a member of the claimant's immediate family designated by the claimant.

"Commission" means the State Corporation Commission.

"Documentation" includes all pertinent communications, including electronic communications and transactions, data, notes, work papers, claim forms, bills, and explanation of benefits forms relative to the claim.

"Estimate" means a written statement of the cost of repairs to an automobile or to property, including any supplements.

"Explanation of benefits" means any form provided by any insurer that explains the amounts covered under a policy or plan and shows the amounts payable by a covered person to a health care provider.

"First party claimant" means an insured, a beneficiary, a policy owner, or an annuitant who asserts a right to payment under an insurance policy arising out of the occurrence of the contingency or loss covered by such policy.

"Insured" means a person covered by an insurance policy with legal rights to the benefits provided by the policy.

"Insurer" means a person licensed to issue or that issues any insurance policy in this Commonwealth. Insurer shall also include surplus lines brokers.

"Investigation" means all activities of an insurer used to make a determination that the claim should be paid, denied, or closed.

"Person" has the same meaning as defined in § 38.2-501 of the Code of Virginia.

"Policy" means insurance policy, contract, certificate of insurance, evidence of coverage, or annuity.

"Proof of loss" means all necessary documentation reasonably required by the insurer to make a determination of benefit or coverage.

"Provider" means any person providing services pursuant to any accident and sickness policy.

"Third party claimant" means any person asserting a claim against an insured or a provider filing a claim on behalf of an insured under an insurance policy.

Statutory Authority

§§ 12.1-13, 38.2-223, and 38.2-510 of the Code of Virginia.

Historical Notes

Derived from Regulation 12, Case No. 19961, § 3, eff. September 15, 1978; amended, Volume 33, Issue 22, eff. January 1, 2018.

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