2007 California Insurance Code Article 5.5. Insurance Claims Analysis Bureaus

CA Codes (ins:1875.10-1875.18)

1875.10.  The Legislature finds and declares as follows:
   (a) That the business of insurance involves many transactions
which have potential for abuse and illegal activities.
   (b) That insurers and their policyholders ultimately pay the cost
of fraudulent insurance claims.
   (c) That the operation of insurance claims analysis bureaus would
be to the benefit of the public, regulators, law enforcement,
prosecutors, and insurers in suppressing and preventing insurance
claims fraud.
   (d) That the purpose of insurance claims analysis bureaus is to
provide a data service to encourage the identification of utilization
patterns by individuals or businesses who provide services in
support of insurance claims, and by individual claimants themselves,
in order to facilitate the identification and prevention of
fraudulent activities.
   (e) That promotion of an effective public-private partnership
between the insurance industry and the commissioner to share data on
suspected fraudulent claims is necessary to avoid unnecessary
duplication and expense in reporting that data.
   (f) It is the intent of the Legislature that, to promote a
data-sharing partnership that is efficient and cost-effective, the
commissioner and the bureau make every effort to obtain suspected
fraudulent claims data from reporting and collection sources already
in existence and supported by the insurance industry, by licensing
those sources as claims analysis bureaus, as provided in this
chapter.


1875.11.  (a) No insurance claims analysis bureau shall conduct any
operations in this state without first filing a written application
with the commissioner and obtaining a license to act in that
capacity.
   (b) As used in this section, an insurance claims analysis bureau
is an organization, duly licensed pursuant to this article, which
collects claims information and data from and disseminates claims
information and data to its members or subscribers which is utilized
for the purpose of the prevention and suppression of insurance fraud.



1875.12.  (a) The commissioner may license an organization as an
insurance claims analysis bureau if it meets the following
qualifications:
   (1) Is a nonprofit corporation organized for the purpose of fraud
prevention or is a corporation that has made the filings required by
Section 1855.2.
   (2) Has at least two years of experience, or has a managing
officer with at least two years of experience, determined by the
commissioner to be relevant to operation of an insurance claims
analysis bureau, or has at least two years' experience collecting and
compiling insurance statistical information.
   (3) Has a member or subscriber base of sufficient size that is, in
the opinion of the commissioner, adequate to assure uniformity in
data collection and cost efficiency to the insurer.
   (4) Maintains its records in a computerized format.
   (b) An applicant seeking a license as an insurance claims analysis
bureau shall file with the commissioner the following documents:
   (1) A copy of its articles of incorporation, its bylaws, and any
rules and regulations governing the conduct of its business.
   (2) A list of members or subscribers.
   (3) A description of its technical capacity to collect and serve
the volume of data necessary to act as an insurance claims analysis
bureau.
   (4) A statement establishing that the applicant meets the
conditions set forth in subdivision (a).
   (5) A certificate signed by an officer of the applicant that it
will permit any licensed insurer to become a member or subscriber to
the insurance claims analysis bureau.
   (6) A statement of all of the following:
   (A) That it will provide admitted insurers subject to Article 6
(commencing with Section 1876) the ability to submit required
information to the claims analysis bureau at no cost to the insurer,
and also provide nonmember or nonsubscriber insurers, at no cost to
the insurer, any software that is specifically designed for the
purpose of submitting information electronically that the bureau
requires its insurers to use.
   (B) That information from its data base will be made available to
state law enforcement agencies pursuant to existing law, and that it
will be made available at no cost to those agencies.
   (c) This section shall not be interpreted to provide any nonmember
or nonsubscriber any rights of membership or subscription in an
organization licensed as an insurance claims analysis bureau.



1875.13.  The commissioner shall license an insurance claims
analysis bureau by class of claims, if an insurance claims analysis
bureau makes application and is appropriately qualified, for the
following classes of claims:
   (a) Automobile bodily injury, which shall include liability,
uninsured motorist, and medical payment.
   (b) Automobile physical damage.
   (c) Automobile theft.
   (d) Fire and allied lines property damage.
   (e) General liability bodily injury.
   (f) Disability.
   (g) Life.
   (h) Workers' compensation.


1875.14.  An insurance claims analysis bureau shall perform the
following functions:
   (a) Collect and compile information and data from members or
subscribers concerning insurance claims.
   (b) Disseminate information to members or subscribers relating to
insurance claims for the purpose of preventing and suppressing
insurance fraud.
   (c) Promote training and education to further insurer
investigation, suppression, and prosecution of insurance fraud.
   (d) Provide, without fee or charge, to the commissioner, all
California data and information contained in the records of the
insurance claims analysis bureau in furtherance of the prevention and
prosecution of insurance fraud.



1875.15.  (a) A licensed insurance claims analysis bureau shall
develop rules governing the kind, quality, and frequency of data
reporting, which shall be binding on all subscribers or members.  The
commissioner may require development of new claims categories for
the suppression and prevention of fraud.
   (b) Every member or subscriber shall report, at a minimum, the
following regarding any category of claims:
   (1) Name of claimant.
   (2) Address of claimant.
   (3) Date of accident or incident.
   (4) Identification of medical provider, if applicable.
   (5) Identification of property repair vendor, if applicable.
   (6) Identification of members or subscribers and, if applicable,
adjusters.
   (7) Identification of attorneys representing claimants, if
applicable.
   (8) Description of claim.
   (9) Claimant's driver license or California Identification card
number, if applicable.
   (10) Claimant's social security number, if known to the insurer.
   (11) Vehicle license numbers, if the claim involves automobile
insurance.
   (12) Vehicle identification numbers, if known and the claim
involves automobile insurance.



1875.16.  Unless otherwise provided by law, any authorized entity
which receives any information furnished pursuant to this article
shall not release that information to public inspection (1) until
such time as its release is required in connection with a criminal or
civil proceeding, or (2) is necessary to analyze and present
information for release in an insurance claims analysis bureau's
annual report.  Any information acquired pursuant to this article
shall not be part of any public record nor subject to disclosure
under the California Public Records Act.



1875.17.  On or before May 1, 1992, and on or before May 1 of each
year thereafter, any licensed insurance claims analysis bureau shall
file with the department a report on the scope and extent of its
activities in this state for the preceding year.




1875.18.  (a) Every bodily injury, medical payment, or uninsured
motorist claim made under a policy of automobile insurance shall be
available, upon request, to law enforcement agencies in this state,
whenever that claim relates to an event that occurred within the
state.
   (b) Every claim subject to subdivision (a) shall be available
without regard to any limitation in the Insurance Information and
Privacy Protection Act (Article 6.6 (commencing with Section 791) of
Chapter 1), or any other provision of law, whether or not the law
enforcement agency has formed a reasonable belief that a violation of
law may have occurred with regard to the claim.
   (c) (1) A licensed insurance claims analysis bureau shall provide
automobile claims information, upon request, to a law enforcement
agency pursuant to the authority in subdivision (a).
   (2) A licensed insurance claims analysis bureau, and any person
employed therein, that provides information pursuant to this section
shall have the same immunity provided under Section 791.21 as any
person disclosing personal or privileged information under Article
6.6 (commencing with Section 791) of Chapter 1.
   (d) (1) Claims information requested by law enforcement agencies,
pursuant to the authority in this section, shall be used solely for
the purpose of investigating and prosecuting automobile insurance
fraud.  Those requests shall be narrowly formulated in order to
protect the privacy rights of citizens of this state, while obtaining
the information necessary to conduct specific investigations.
   (2) The commissioner shall establish rules governing the access
to, and use of, any information requested or obtained pursuant to
this section, and the circumstances under which that information may
be inspected and corrected.