Sec. 38a-9. (Formerly Sec. 38-4b). Divisions of Consumer Affairs and Rate Review. Duties. Annual reports by commissioner. Arbitration procedure. (a) Notwithstanding the provisions of section 4-8, there shall be a Division of Consumer Affairs within the Insurance Department, which division shall act on the Insurance Commissioner's behalf and at his direction in order to carry out his responsibilities under this title with respect to such matters. The division shall receive and review complaints from residents of this state concerning their insurance problems, including claims disputes, and serve as a mediator in such disputes in order to assist the commissioner in determining whether statutory requirements and contractual obligations within the commissioner's jurisdiction have been fulfilled. There shall be a director of said division, who shall be provided with sufficient staff. The division shall serve to coordinate all appropriate facilities in the department in addressing such complaints, and conduct any outreach programs deemed necessary to properly inform and educate the public on insurance matters. The director shall submit quarterly reports to the commissioner, which shall state the number of complaints received by the division in such calendar quarter, the Connecticut premium volume of the appropriate line of each insurance company against which a complaint has been filed, the types of complaints received, and the number of such complaints which have been resolved. Such reports shall be published every six months and copies shall be made available to any interested resident of this state upon request. The commissioner shall report, in accordance with section 11-4a, to the joint standing committee of the General Assembly having cognizance of matters relating to insurance on or before January fifteenth annually, concerning the findings of such reports and suggestions for legislative initiatives to address recurring problems.
(b) (1) The Division of Consumer Affairs shall provide an independent arbitration procedure for the settlement of disputes between claimants and insurance companies concerning automobile physical damage and automobile property damage liability claims in which liability and coverage are not in dispute. Such procedure shall apply only to disputes involving private passenger motor vehicles as defined in subsection (e) of section 38a-363. Any company licensed to write private passenger automobile insurance, including collision, comprehensive and theft, in this state shall participate in the arbitration procedure. The commissioner shall appoint an administrator for such procedure. Only those disputes in which attempts at mediation by the Division of Consumer Affairs have failed shall be accepted as arbitrable. The referral of the complaint to arbitration shall be made by the Insurance Department examiner who investigated the complaint. Each party to the dispute shall pay a filing fee of twenty dollars. The insurance company shall pay the claimant the undisputed amount of the claim upon written notification from the department that the complaint has been referred to arbitration. Such payment shall not affect any right of the claimant to pursue the disputed amount of the claim.
(2) The commissioner shall prepare a list of at least ten persons, who have not been employed by the department or an insurance company during the preceding twelve months, to serve as arbitrators in the settlement of such disputes. The arbitrators shall be members of any dispute resolution organization approved by the commissioner. One arbitrator shall be appointed to hear and decide each complaint. Appointment shall be based solely on the order of the list. If an arbitrator is unable to serve on a given day, or if either party objects to the arbitrator, then the next arbitrator on the list shall be selected. The department shall schedule arbitration hearings as often, and in such locations, as it deems necessary. Parties to the dispute shall be provided written notice of the hearing at least ten days prior to the hearing date. The commissioner may issue subpoenas on behalf of the arbitrator to compel the attendance of witnesses and the production of documents, papers and records relevant to the dispute. Decisions shall be made on the basis of the evidence presented at the arbitration hearing. Where the arbitrator believes that technical expertise is necessary to decide a case, such arbitrator may consult with an independent expert recommended by the commissioner. The arbitrator and any independent technical expert shall be paid by the department on a per dispute basis as established by the commissioner. The arbitrator, as expeditiously as possible but not later than fifteen days after the arbitration hearing, shall render a written decision based on the information gathered and disclose the findings and the reasons to the parties involved. The arbitrator shall award filing fees to the prevailing party. If the decision favors the claimant, (A) the decision shall provide specific and appropriate remedies including interest at the rate of fifteen per cent per year on the arbitration award concerning the disputed amount of the claim, retroactive to the date of payment for the undisputed amount of the claim, and (B) the arbitrator shall require the insurance company to reimburse the department for the department's costs incurred in connection with the administration of the arbitration hearing, unless such claimant rejected such insurance company's prearbitration offer of compromise of equal or greater value than the arbitration award. The decision may include costs for loss of use and storage of the motor vehicle and shall specify a date for performance and completion of all awarded remedies. Notwithstanding any provision of the general statutes or any regulation, the Insurance Department shall not amend, reverse, rescind, or revoke any decision or action of any arbitrator. The department shall contact the claimant not later than ten business days after the date for performance, to determine whether performance has occurred. Either party may make application to the superior court for the judicial district in which one of the parties resides or, when the court is not in session, any judge thereof for an order confirming, vacating, modifying or correcting any award, in accordance with the provisions of sections 52-417, 52-418, 52-419 and 52-420. If it is determined by the court that either party's position after review has been improved by at least ten per cent over that party's position after arbitration, the court may grant to that party its costs and reasonable attorney's fees. No evidence, testimony, findings, or decision from the department arbitration procedure shall be admissible in any civil proceeding, except judicial review of the arbitrator's decision as contemplated by this subsection.
(3) The department shall maintain records of each dispute, including names of parties to the arbitration, the decision of the arbitrator, compliance, the appeal, if any, and the decision of the court. The department shall annually compile such statistics and send a copy to the committee of the General Assembly having cognizance of matters relating to insurance. The report shall be considered a public document.
(c) Notwithstanding the provisions of section 4-8, there shall be a Division of Rate Review within the Insurance Department, which division shall act on the commissioner's behalf and at the commissioner's direction in order to carry out the commissioner's responsibilities under this title with respect to such matters. Subject to the provisions of sections 38a-663 to 38a-696, inclusive, the division shall assist the commissioner in reviewing rates and supplementary rate information filed with the department for compliance with statutory requirements and standards. The division's staff shall include rating examiners with sufficient actuarial expertise. Upon the request of the commissioner, the division shall review rates and supplementary rate information, and any suspected violation of the statutory requirements and standards of sections 38a-663 to 38a-696, inclusive, found pursuant to such review shall be referred to the commissioner for appropriate action. The division may assist the commissioner in formalizing the commissioner's findings regarding such actions. The commissioner shall report, in accordance with section 11-4a, to the joint standing committee of the General Assembly having cognizance of matters relating to insurance on or before January fifteenth annually, concerning (1) the number and type of reviews conducted by the division in the prior calendar year, and (2) the percentage of increase or decrease in rates reviewed by the division during the preceding calendar year, by line and subline of insurance.
(d) The directors and staff of both the Division of Consumer Affairs and the Division of Rate Review shall be appointed by the commissioner under the provisions of chapter 67.
(P.A. 87-515, S. 1, 4; P.A. 88-326, S. 9, 11; P.A. 96-227, S. 1; P.A. 99-145, S. 2, 23; P.A. 01-174, S. 1; P.A. 09-74, S. 1, 2; P.A. 10-5, S. 1; 10-7, S. 8; P.A. 13-134, S. 2; P.A. 25-131, S. 1.)
History: P.A. 88-326 required the Connecticut premium volume of the line of each insurance company against which a complaint has been filed to be stated in quarterly reports to the commissioner, required reports from the director to be published and made available every six months, and inserted a new Subsec. (b) establishing an arbitration procedure for automobile damage claims, relettering existing Subsecs. as necessary, effective July 1, 1989; Sec. 38-4b transferred to Sec. 38a-9 in 1991; (Revisor's note: In 1997 a reference in Subsec. (b)(2) to “Department of Insurance” was changed editorially by the Revisors to “Insurance Department” for consistency with customary statutory usage); P.A. 96-227 amended Subsec. (c) to delete the requirement that the division director be a member of the American Academy of Actuaries; P.A. 99-145 amended Subsec. (b) to substitute “subsection (e) of section 38a-363” for “subsection (g) of section 38a-363”, effective June 8, 1999; P.A. 01-174 deleted Subsec. (c)(3) re reports to the General Assembly concerning filed rates found to be a suspected violation of statutory requirements and standards, substituted references to Sec. 38a-696 for references to Sec. 38a-697, and made technical changes for purposes of gender neutrality; P.A. 09-74 made technical changes in Subsecs. (a) and (c), effective May 27, 2009; P.A. 10-5 made technical changes in Subsec. (b)(2), effective May 5, 2010; P.A. 10-7 amended Subsec. (b)(2) to make a technical change, increase arbitration award interest rate from 10% to 15% and specify that such interest rate is per year, effective January 1, 2011; P.A. 13-134 replaced “consumer” with “claimant” in Subsec. (b)(1) and (2); P.A. 25-131 amended Subsec. (b)(2) by designating existing requirement re appropriate remedies as Subpara. (A) and by designating new requirement re insurance companies to reimburse Insurance Department for arbitration costs where claimant prevails as Subpara. (B).
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Sec. 38a-16. (Formerly Sec. 38-7a). Investigations and hearings by Insurance Commissioner. Subpoenas. Injunctive relief. (a)(1) The Insurance Commissioner or the commissioner's authorized representative may, as often as the commissioner deems necessary, conduct investigations and hearings in aid of any investigation on any matter under the provisions of this title. Pursuant to any such investigation or hearing, the commissioner or the commissioner's authorized representative may issue data calls and subpoenas, administer oaths, compel testimony, order the production of books, records, papers and documents and examine books and records. Any person in receipt of an order from the commissioner or the commissioner's authorized representative for the production of books, records, papers or documents shall comply with the order not later than thirty calendar days after the date of such order. If any person refuses to allow the examination of books and records, to appear, to testify or to produce any book, record, paper or document when so ordered, a judge of the Superior Court, upon application of the commissioner or the commissioner's authorized representative, may make such order as may be appropriate to aid in the enforcement of this section.
(2) Data provided in response to a data call under this section shall not be subject to disclosure under section 1-210.
(b) The Attorney General, at the request of the commissioner, is authorized to apply in the name of the state of Connecticut to the Superior Court for an order temporarily or permanently restraining and enjoining any person from violating any provision of this title.
(P.A. 86-95, S. 2, 3; P.A. 09-74, S. 7; P.A. 16-213, S. 2; P.A. 24-138, S. 3; P.A. 25-69, S. 1.)
History: Sec. 38-7a transferred to Sec. 38a-16 in 1991; P.A. 09-74 made technical changes in Subsec. (a), effective May 27, 2009; P.A. 16-213 amended Subsec. (a) by designating existing provisions as Subdiv. (1) and amending same by authorizing commissioner to issue data calls and by adding Subdiv. (2) re data provided in response to data call; P.A. 24-138 amended Subsec. (a) re compliance with orders for production of books, records, papers or documents; P.A. 25-69 made technical changes in Subsec. (a), effective June 23, 2025.
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Sec. 38a-21. Review and evaluation of mandated health benefits. Costs and assessments. Commissioner may contract with independent expert. Report. (a) As used in this section:
(1) “Commissioner” means the Insurance Commissioner.
(2) “Mandated health benefit” means an existing statutory obligation of, or proposed legislation that would require, an insurer, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that offers individual or group health insurance or medical or health care benefits plan in this state to: (A) Permit an insured or enrollee to obtain health care treatment or services from a particular type of health care provider; (B) offer or provide coverage for the screening, diagnosis or treatment of a particular disease or condition; or (C) offer or provide coverage for a particular type of health care treatment or service, or for medical equipment, medical supplies or drugs used in connection with a health care treatment or service. “Mandated health benefit” includes any proposed legislation to expand or repeal an existing statutory obligation relating to health insurance coverage or medical benefits.
(b) (1) There is established within the Insurance Department a health benefit review program for the review and evaluation of any mandated health benefit that is requested by the joint standing committee of the General Assembly having cognizance of matters relating to insurance. Such program shall be funded by the Insurance Fund established under section 38a-52a. The commissioner shall be authorized to make assessments in a manner consistent with the provisions of chapter 698 for the costs of carrying out the requirements of this section. Such assessments shall be in addition to any other taxes, fees and moneys otherwise payable to the state. The commissioner shall deposit all payments made under this section with the State Treasurer. The moneys deposited shall be credited to the Insurance Fund and shall be accounted for as expenses recovered from insurance companies. Such moneys shall be expended by the commissioner to carry out the provisions of this section and section 2 of public act 09-179*.
(2) The commissioner may engage the services of any actuary, actuarial firm, quality improvement clearinghouse, health policy research organization or any other independent expert as the commissioner deems necessary to assist the commissioner in the review and evaluation of any mandated health benefit review requested pursuant to subsection (c) of this section.
(c) Not later than August first of each year, the joint standing committee of the General Assembly having cognizance of matters relating to insurance shall submit to the commissioner a list of any mandated health benefits for which said committee is requesting a review. Not later than January first of the succeeding year, the commissioner shall submit a report, in accordance with section 11-4a, of the findings of such review and the information set forth in subsection (d) of this section.
(d) The review report shall include at least the following, to the extent information is available:
(1) The social impact of mandating the benefit, including:
(A) The extent to which the treatment, service or equipment, supplies or drugs, as applicable, is utilized by a significant portion of the population;
(B) The extent to which the treatment, service or equipment, supplies or drugs, as applicable, is currently available to the population, including, but not limited to, coverage under Medicare, or through public programs administered by charities, public schools, the Department of Public Health, municipal health departments or health districts or the Department of Social Services;
(C) The extent to which insurance coverage is already available for the treatment, service or equipment, supplies or drugs, as applicable;
(D) If the coverage is not generally available, the extent to which such lack of coverage results in persons being unable to obtain necessary health care treatment;
(E) If the coverage is not generally available, the extent to which such lack of coverage results in unreasonable financial hardships on those persons needing treatment;
(F) The level of public demand and the level of demand from providers for the treatment, service or equipment, supplies or drugs, as applicable;
(G) The level of public demand and the level of demand from providers for insurance coverage for the treatment, service or equipment, supplies or drugs, as applicable;
(H) The likelihood of achieving the objectives of meeting a consumer need as evidenced by the experience of other states;
(I) The relevant findings of state agencies or other appropriate public organizations relating to the social impact of the mandated health benefit;
(J) The alternatives to meeting the identified need, including, but not limited to, other treatments, methods or procedures;
(K) Whether the benefit is a medical or a broader social need and whether it is consistent with the role of health insurance and the concept of managed care;
(L) The potential social implications of the coverage with respect to the direct or specific creation of a comparable mandated benefit for similar diseases, illnesses or conditions;
(M) The impact of the benefit on the availability of other benefits currently offered;
(N) The impact of the benefit as it relates to employers shifting to self-insured plans and the extent to which the benefit is currently being offered by employers with self-insured plans;
(O) The impact of making the benefit applicable to the state employee health insurance or health benefits plan; and
(P) The extent to which credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community determines the treatment, service or equipment, supplies or drugs, as applicable, to be safe and effective; and
(2) The financial impact of mandating the benefit, including:
(A) The extent to which the mandated health benefit may increase or decrease the cost of the treatment, service or equipment, supplies or drugs, as applicable, over the next five years;
(B) The extent to which the mandated health benefit may increase the appropriate or inappropriate use of the treatment, service or equipment, supplies or drugs, as applicable, over the next five years;
(C) The extent to which the mandated health benefit may serve as an alternative for more expensive or less expensive treatment, service or equipment, supplies or drugs, as applicable;
(D) The methods that will be implemented to manage the utilization and costs of the mandated health benefit;
(E) The extent to which insurance coverage for the treatment, service or equipment, supplies or drugs, as applicable, may be reasonably expected to increase or decrease the insurance premiums and administrative expenses for policyholders;
(F) The extent to which the treatment, service or equipment, supplies or drugs, as applicable, is more or less expensive than an existing treatment, service or equipment, supplies or drugs, as applicable, that is determined to be equally safe and effective by credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community;
(G) The impact of insurance coverage for the treatment, service or equipment, supplies or drugs, as applicable, on the total cost of health care, including potential benefits or savings to insurers and employers resulting from prevention or early detection of disease or illness related to such coverage;
(H) The impact of the mandated health care benefit on the cost of health care for small employers, as defined in section 38a-564, and for employers other than small employers; and
(I) The impact of the mandated health benefit on cost-shifting between private and public payors of health care coverage and on the overall cost of the health care delivery system in the state.
(P.A. 09-179, S. 1; P.A. 25-132, S. 1.)
*Note: Section 2 of public act 09-179 is special in nature and therefore has not been codified but remains in full force and effect according to its terms.
History: P.A. 09-179 effective July 1, 2009; P.A. 25-132 amended Subsec. (b)(2) to replace contractual requirements re University of Connecticut Center for Public Health and Health Policy with language providing commissioner with discretion to retain the services of any independent expert.
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