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Subject 120-2-20 UNFAIR TRADE AND CLAIMS SETTLEMENT PRACTICES

Rule 120-2-20-.01 Soliciting in General

It is hereby determined that the commission of any of the following acts or practices by any insurer, agent, counselor, solicitor or broker transacting property, marine, casualty or surety insurance in Georgia constitutes an unfair method of competition and an unfair and deceptive act or practice prohibited by Article 1 of Chapter 6 of Title 33 of the Official Code of Georgia Annotated and the same are hereby prohibited:

(1) Making, publishing, disseminating, circulating or placing before the public or any group of persons in written, printed, or any other form, including radio or televisions broadcasts, any advertisement, announcement, solicitation, or statement pertaining to any form of property, marine, casualty or surety insurance which appears to emanate from, through or under the auspices of any trade, social, fraternal or professional association or organization, creditor to persons severally indebted, labor union, employee group, or other similar association, organization, or group not authorized to transact the business of such form of insurance in Georgia, where such advertisement, announcement, solicitation or statement expressly or by implication represents, or can be reasonably construed to mislead the recipient into believing, that any insurance premium or policy coverage described therein constitutes a special or preferred advantage to, or is only available to, such group or any of its members, when such representation or implication is false or, if true, would constitute use of a discriminatory rate or an offering to a fictitious group, prohibited by law.
(2) Knowingly allowing any other person to make, publish, disseminate, circulate or place before the public or any group of persons any advertisement, announcement, solicitation or statement prohibited by the preceding paragraph (1) hereof.
(3) The provisions of this Regulation shall not extend to life, accident and sickness insurance, nor shall they apply to any bona fide association group composed of members employed in a common trade, business or profession, and which has had group insurance of the same type continuously in existence for at least since January 1, 1956.

Rule 120-2-20-.02 Time Limitation on Filing Suit

No property, casualty, credit, marine and transportation, or vehicle insurance policy providing first party insurance coverage for loss or damage to any type of real or personal property shall contain a contractual limitation requiring commencement of a suit or action within a specified period of time less favorable to the insured than that specified in the "Standard Fire Policy" promulgated by the Commissioner in Chapter 120-2-19-.01 of these Rules and Regulations. The time limitation on filing suit imposed by this Rule is applicable only to the portion or portions of the policies providing first party property insurance coverage. Liability coverage and workers compensation coverage are specifically exempted from the requirements of this Rule.

Rule 120-2-20-.03 Unlawful Agreements between Insurers and Providers

(1) An agreement between an insurer and a provider shall not include a most favored nation clause or an upper limit trigger clause.
(2) Definitions:
(a) "Most favored nation clause" means any clause or combination of clauses in an agreement between an insurer and a provider that:
1. Prohibits, or grants the insurer an option to prohibit, a provider from contracting with another party to provide health care services at a lower rate than the payment or reimbursement rate specified in the contract;
2. Requires, or grants the insurer an option to require, a provider to accept a lower payment or reimbursement rate if the provider agrees to provide health care services to another party at a lower rate than the payment or reimbursement rate specified in the contract;
3. Requires, or grants a contracting insurer an option to terminate or renegotiate an existing contract in the event the provider agrees to provide health care services to any other party at a lower rate; or
4. Requires a provider to disclose, to the insurer or its designee, the provider's contractual payment or reimbursement rates with other parties.
(b) "Upper limit trigger clause" means any clause or combination of clauses in an agreement between an insurer (the "first insurer") and a provider that requires the provider to cease accepting as patients individuals covered by an agreement with another insurer, or non-covered patients, if the provider elects to limit, or cease, accepting patients covered by the agreement between the first insurer and the provider. As used in this Regulation, the term "upper limit trigger clause" only refers to a clause or combination of clauses contained within an agreement between an insurer and a provider where the provider is a primary care physician and is compensated by the insurer on a capitated basis.
(3) The Commissioner shall follow the procedure set forth in O.C.G.A. § 33-6-13(d)whenever there is a violation of this regulation.
(4) For the purposes of this regulation, "provider" means any physician, hospital, or other person who is licensed or otherwise authorized in this state to furnish health care services.
(5) For the purposes of this regulation, "health care services" means any services included in the furnishing to any individual of medical or dental care or hospitalization or incident to the furnishing of such care or hospitalization, as well as the furnishing to any person of any and all other services for the purpose of preventing, alleviating, curing, or healing human illness or injury.

Rule 120-2-20-.04 Severability

If any rule or portion thereof contained in this Chapter is held invalid by a court of competent jurisdiction, the remainder of the rules herein and the applicability of such provisions to other circumstances shall not be affected thereby.