PURPOSE: This rule sets forth definitions used in 20 CSR 100-1 of the Code of State Regulations.

1. (1) Definitions. As used in the Unfair Claims Settlement Practices Act at sections 375.1000 to 375.1018, RSMo and in the regulations promulgated pursuant thereto—

   1. (A) Agent means any individual, corporation, association, partnership or other legal entity authorized to represent an insurer with respect to a claim;

   2. (B) Claim means—

      1. 1. A request or demand for payment of

a loss which may be included within the terms of coverage of an insurance policy; or

1. 2. A request or demand for any other

payment under the policy, such as for the return of unearned premium or nonforfeiture benefits;

1. (C) Claimant means any—

   1. 1. First-party claimant, including a sub-

scriber under any plan providing health services;

1. 2. Third-party claimant; or
2. 3. Person or entity submitting a claim on

behalf of any insured and includes the claimant’s designated legal representative and a member of the claimant’s immediate family designated by the claimant;

1. (D) First-party claimant means any individual, corporation, association, partnership or other legal entity asserting a right to payment arising out of the occurrence of a contingency or loss covered by an insurance policy;
2. (E) Insurer means any legal entity organized, incorporated or doing business under the provisions of Chapter(s) 354, 375–379, 381 or 383, RSMo or otherwise engaged in the business of insurance in this state;
3. (F) Investigation means all activities of an insurer directly or indirectly related to the determination of liabilities under coverages afforded by an insurance policy;
4. (G) Notification of claim means any notification, whether in writing or by other means acceptable under the terms of an insurance policy to an insurer or its agent, by a claimant, which reasonably apprises the insurer of the facts pertinent to a claim;
5. (H) Third-party claimant means any individual, corporation, association, partnership or other legal entity asserting a claim against any individual, corporation, association, partnership or other legal entity insured under an insurance policy;
6. (I) Insurance policy means any insurance contract, certificate of insurance or contract under which health services are to be provided; and

7. (J) Time error rate refers to any one (1) of the following:

   1. 1. Acknowledgment time error rate, the

percentage of claims in which the insurer has performed an act described in section 375.1007(2), RSMo, or violated 20 CSR 100-1.030;

1. 2. Investigation time error rate, the per-

centage of claims in which the insurer has performed an act described in section 375.1007(3), RSMo, or violated 20 CSR 100-1.030; or

1. 3. Determination time error rate, the

percentage of claims in which the insurer has performed an act described in section 375.1007(7), RSMo, or violated 20 CSR 100-1.050. AUTHORITY: sections 374.045, RSMo Supp. 1997 and 375.1000-375.1018, RSMo 1994 and Supp. 1998.* This rule was previously filed as 4 CSR 190-10.060(1). Original rule filed Aug. 5, 1974, effective Aug. 15, 1974. Rescinded and readopted: Filed Aug. 16, 1978, effective Dec. 11, 1978. Amended: Filed Sept. 11, 1980, effective Feb. 16, 1981. Amended: Filed Sept. 14, 1981, effective Jan. 15, 1982. Amended: Filed Aug. 4, 1986, effective Jan. 1, 1987. Amended: Filed Jan. 5, 1987, effective June 1, 1987. Amended: Filed Aug. 4, 1987, effective Dec. 24, 1987. Amended: Filed Dec. 9, 1988, effective April 28, 1989. Amended: Filed Nov. 2, 1989, effective Feb. 15, 1990. Emergency amendment filed Feb. 21, 1990, effective March 5, 1990, expired June 2, 1990. Amended: Filed Feb. 26, 1990, effective June 11, 1990. Amended: Filed Dec. 12, 1990, effective June 10, 1991. Amended: Filed Oct. 1, 1996, effective June 30, 1997. Amended: Filed Dec. 1, 1998, effective July 30, 1999. *Original authority 374.045, RSMo 1967, amended 1993, 1995; 375.1000–375.1018, see Missouri Revised Statutes 1994, and Missouri Revised Statutes Cumulative Supplement 1998.