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CA INSURANCE CARRIER SIU REQUIREMENTS EXPLAINED
“A carrier can have multiple “reporting parties.” That can mean either an internal SIU plus a contracted SIU, or more than one contracted SIU. — Natalie Chandler, Manager of SIU Compliance at the California Department of Insurance,
- Insurers licensed to conduct business in California are required by California Insurance Code Sections 1875.20-24 and California Code of Regulations, Title 10, Sections 2698.30 - .43 to establish and maintain Special Investigative Units (SIU) that identify and refer suspected workers’ compensation insurance fraud to both, the California Department of Insurance (CDI) and the California County District Attorney’s Office (DA). (This is done by the carrier’s internal SIU or contracted SIU)
- "Special Investigative Unit" (SIU) means an insurer's unit or division that is established to investigate suspected insurance fraud. The SIU may be comprised of insurer employees or by contracting with other entities for the purpose of complying with applicable sections of the Insurance Frauds Prevention Act (IFPA) for the direct responsibility of performing the functions and activities as set forth in these regulations.
- The regulations also require each insurer to submit a SIU Annual Report to the CDI which provides important information regarding the insurer’s anti-fraud operations, procedures, and training materials. (This is done by the carrier’s internal SIU or contracted SIU)
- Identification and referral of red flag, red flag event, or circumstances to SIU that supports an inference that insurance fraud may have been committed.
- Reporting of fraud must be made to both the CDI and DA within 60 days of SIU investigation completion, if determined that reasonable belief of insurance fraud exists. (This is done by submission of the online eFD-1 through the fraud portal with CDI)
- Provide annual Anti-Fraud Training to claims examiner personnel within the calendar year.
- Adhere to request for claim files from governmental agencies, being within 60 days. (This pertains to 1877 demand letters from CDI/DA)
- Adhere to requests and information from CDI’s SIU Compliance Office.
August 7, 2024
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