§ 58-39-55. Reasons for adverse underwriting decisions. - North Carolina Statutes

§ 58‑39‑55. Reasons for adverse underwriting decisions.

(a)        In the event of anadverse underwriting decision, the insurance institution or agent responsiblefor the decision shall give a written notice in a form approved by theCommissioner that:

(1)        Either provides theapplicant, policyholder, or individual proposed for coverage with the specificreason or reasons for the adverse underwriting decision in writing or advisessuch person that upon written request he may receive the specific reason orreasons in writing; and

(2)        Provides theapplicant, policyholder, or individual proposed for coverage with a summary ofthe rights established under subsection (b) of this section and G.S. 58‑39‑45and 58‑39‑50.

(b)        Upon receipt of awritten request within 90 business days from the date of the mailing of noticeor other communication of an adverse underwriting decision to an applicant,policyholder or individual proposed for coverage, the insurance institution oragent shall furnish to such person within 21 business days from the date ofreceipt of such written request:

(1)        The specific reasonor reasons for the adverse underwriting decision, in writing, if suchinformation was not initially furnished in writing pursuant to subdivision(a)(1) of this section;

(2)        The specific itemsof personal and privileged information that support those reasons: Provided,however:

a.         The insuranceinstitution or agent shall not be required to furnish specific items ofprivileged information if it has a reasonable suspicion, based upon specificinformation available for review by the Commissioner, that the applicant,policyholder, or individual proposed for coverage has engaged in criminalactivity, fraud, material misrepresentation, or material nondisclosure, and

b.         Specific items ofmedical‑record information supplied by a medical‑care institutionor medical professional shall be disclosed either directly to the individualabout whom the information relates or to the medical professional designated bythe individual and licensed to provide medical care with respect to thecondition to which the information relates, whichever the insurance institutionor agent prefers; and

(3)        The names andaddresses of the institutional sources that supplied the specific items ofinformation given pursuant to subdivision (b)(2) of this section: Provided,however, the identity of any medical professional or medical‑careinstitution shall be disclosed either directly to the individual or to thedesignated medical professional, whichever the insurance institution or agentprefers.

(c)        The obligationsimposed by this section upon an insurance institution or agent may be satisfiedby another insurance institution or agent authorized to act on its behalf.

(d)        When an adverseunderwriting decision results solely from an oral request or inquiry, theexplanation of reasons and summary of rights required by this section may begiven orally. (1981,c. 846, s. 1; 2003‑262, s. 2(1).)