SECTION 5.1502. Grievance and Hearing Procedures

Each insurer shall file its written procedures with the Director of Professional Liability Insurance, Mail Code 012-4, State Board of Insurance, 1110 San Jacinto Boulevard, Austin, Texas 78701-1998, within 60 days after the effective date of this section and, thereafter, when these procedures are amended. The director shall review each filing for compliance with the following criteria.

(1) The insurer must file with the Professional Liability Division of the State Board of Insurance the names, titles, and mailing addresses of at least two officers or employees responsible for receiving, reviewing, and hearing any grievance.

(2) Prior to a request for hearing, the insured must file a written grievance with the insurer including a short and plain statement of the matters asserted.

(3) Upon receipt of the insured's written grievance, the insurer shall promptly provide a written response to the grievance, by certified mail to the insured's last known address, with a copy to the Professional Liability Division of the State Board of Insurance.

(4) If the matter in dispute is not resolved to the insured's satisfaction, the insured may request a hearing.

(5) Upon receiving an insured's written request for a hearing, the insurer shall promptly provide, by certified mail to the insured's last known address, with a copy to the Professional Liability Division of the State Board of Insurance, a written notice of a hearing which shall include:

(A) the time, place, and nature of the hearing;

(B) a reference to the Insurance Code, Article 5.15-1, §4B, and to this section; and

(C) an explanation of any procedures to be followed at, or prior to, the hearing.

(6) The hearing date should be scheduled no less than 10 nor more than 30 days after the date upon which the insurer mails a notice letter to the insured, pursuant to this section. If necessary, the parties may reschedule the hearing for a mutually agreeable time or continue the hearing from time to time and place to place. The hearing may take place at the insurer's premises, the insured's premises, or any other location within this state convenient to the insured.

(7) The hearing must be held before the officers or employees of the insurer who have responsibility for determining rates and premiums to be charged for professional liability insurance. The insured must be afforded an opportunity to present evidence and argument on all issues involved. The insurer may swear any witnesses and take their testimony under oath. The hearing should be recorded either electronically or stenographically. A transcript shall be provided upon the request of either party, with the cost to be borne by the requesting party.

(8) The insurer shall reconsider the rate or premium charged the insured and render its final decision on the contested hearing within 60 days after the date the hearing is finally closed. The final decision shall be in writing and include specific findings of fact, which shall be confined exclusively to the evidence presented at the hearing. It shall also include a written explanation of the rate or premium being charged, if the final decision is adverse to the insured. The insurer must inform the insured in writing of the insured's right to appeal an adverse decision to the State Board of Insurance under the Insurance Code, Article 5.15-1, §4B, and §5.1503 of this title (relating to Appeal to the State Board of Insurance).

Source Note: The provisions of this §5.1502 adopted to be effective September 19, 1990, 15 TexReg 5137.