Unfair Claims Settlement Practices Compliance Checklist

Audit template for claim files to verify acknowledgment, investigation, communication, and payment timelines align with state unfair claims settlement practices requirements and NAIC model act expectations.

Audit Identification

• Claim file identifier recorded
  Enter the claim number or file reference reviewed.
• Line of business identified
  Select the claim type being audited.
• Applicable state jurisdiction documented
  Enter the state governing the claim handling timeline review.
• Audit date and reviewer recorded
  Record when the audit was performed and by whom.
• Reference standard noted
  Document the applicable state unfair claims settlement practices rule or NAIC model act reference used for the review.

Claim Acknowledgment and Initial Contact

• Claim acknowledgment sent within required timeframe
  Confirm the first acknowledgment to the claimant or insured was issued within the applicable state deadline.
• Acknowledgment date documented in file
  Record the date and time the acknowledgment was sent or logged.
• Initial contact method appropriate and documented
  Confirm the contact method used is documented and appropriate for the claim file.
• Required claim information request issued
  Confirm any request for missing information or documentation was sent promptly and is retained in the file.
• No unexplained delay in first response
  Rate whether the file shows any avoidable delay in the first response to the claim.

Investigation and Communication

• Investigation initiated within required timeframe
  Confirm investigation activity began within the applicable state or company standard.
• Relevant facts and documents obtained
  Confirm the file contains the key statements, records, photos, estimates, or other evidence needed to support the claim decision.
• Status updates provided at required intervals
  Confirm the claimant or insured received timely status updates when the investigation was pending.
• Requests for additional information were specific and documented
  Confirm any follow-up requests clearly identified what was needed and why.
• Investigation notes support claim handling decisions
  Rate the adequacy of documentation supporting the adjuster's conclusions and actions.

Coverage, Liability, and Decision Basis

• Coverage position documented
  Confirm the file clearly states the coverage determination and basis for that position.
• Liability or causation analysis documented where applicable
  Confirm the file includes a reasonable analysis of liability, causation, or compensability as applicable to the claim type.
• Denial or partial denial supported by facts and policy language
  Confirm any denial, reservation, or partial denial is supported by documented facts and the applicable policy or statutory basis.
• Decision communication sent promptly
  Confirm the decision was communicated within the required timeframe after the investigation was complete.

Payment Timeliness and Settlement Handling

• Undisputed payment issued within required timeframe
  Confirm any undisputed amount was paid within the applicable state deadline after receipt of sufficient proof of loss or agreement on amount.
• Payment date documented
  Record the date payment was issued or authorized.
• Settlement offer amount documented when applicable
  Enter the settlement offer or paid amount reviewed.
• No unreasonable delay in payment processing
  Rate whether the file shows avoidable delay in issuing payment or settlement.
• Release or settlement documentation complete
  Confirm any release, settlement agreement, or closure documentation is complete and retained in the file.

Exceptions, Deficiencies, and Corrective Actions

• Deficiencies identified
  Select all compliance deficiencies observed during the audit.
• Corrective action documented
  Describe the corrective action, owner, and due date for any identified non-conformance.
• Inspector signature
  Inspector signs to confirm the audit findings are complete and accurate.