The Consumer Assistance Unit is responsible for investigating many types of insurance-related inquiries and complaints that fall within the jurisdiction of the Department of Banking and Insurance. Requests for assistance or inquiries involving all lines of insurance (other than Managed Care medical complaints) must be submitted to our Department through the Consumer Inquiry and Response Center (CIRC).
The Enforcement Unit is responsible for investigating cases of alleged violations of New Jersey’s insurance laws. Such cases may be referred to the Enforcement Unit from various Units within the Department, such as Consumer Assistance. The Unit investigates insurance-related allegations made against agents, brokers, insurance companies or other persons or entities licensed or regulated by the Department. The Unit also investigates allegations made against unlicensed persons or entities that may sell insurance from or within our State.
In addition, the Enforcement Unit is responsible for processing any administrative penalties that may be imposed by the Department for non-compliance with our insurance laws. As necessary, the Enforcement Unit will work with the Office of the Attorney General in prosecuting persons or entities that allegedly have violated the State’s insurance laws. Finally, the Enforcement Unit works closely on issues of common interest with New Jersey’s Office of the Insurance Fraud Prosecutor, the New Jersey Bureau of Securities and other State agencies, as well as with the U.S. Department of Labor, the Financial Industry Regulatory Authority (FINRA), other states and law enforcement agencies.
The OMC also oversees the Independent Health Care Appeals Program (IHCAP). After a member or a provider, with the member’s consent, exhausts a carrier’s internal UM appeal process, the member or provider has a right to access the Stage 3 (external appeal) process through the IHCAP administered by the Department of Banking and Insurance (DOBI). DOBI contracts with independent utilization review organizations (IURO) to conduct the Stage 3 reviews for the IHCAP. The IURO’s determination is binding on the carrier. Provider complaints regarding carrier payment issues are also reviewed and investigated through DOBI’s Provider Prompt Payment Unit (PPPU) in the OMC. The PPPU also oversees DOBI’s Program for Independent Claims Payment Arbitration (PICPA).
The Market Conduct Examinations Unit within the Office of Consumer Protection Services conducts on-site examinations of insurance company and agency operations and business practices to determine whether consumers, medical providers and other members of the public are being treated fairly and in accordance with New Jersey insurance laws. The unit examines life, health, managed care and property/casualty companies, with specialty lines reviewed as appropriate. For insurers that are subject to N.J.S.A. 17:33A, the New Jersey Insurance Fraud Prevention Act, and N.J.A.C. 11:16-6, the on-site examination also will include review to determine compliance with fraud prevention, detection and reporting standards required by law.