31 Pa. Code § 146.7

Section 146.7 requires an insurer to advise a first-party claimant within 15 working days after receiving properly executed proofs of loss whether the claim is accepted or denied, but it is enforceable only by the Insurance Commissioner and does not create a policy obligation unless incorporated into the insurance policy.

LIVE FACE ON WEB, LLC v. MERCHANTS INSURANCE GROUP · filed 2020-04-01

In particular, Live Face focuses on the Pennsylvania Administrative Code, which states, in relevant part: “Within 15 working days after receipt by the insurer of properly executed proofs of loss, the first-party claimant shall be advised of the acceptance or denial of the claim by the insurer.” 31 Pa. Code § 146.7. According to Live Face, this provision barred Merchants from revisiting its decision to accept coverage for the accident. Thus, goes Live Face’s logic, by breaching this regulation, Merchants breached the Policy. That argument fails for several reasons. First, only the Pennsylvania Insurance Commissioner can enforce the UIPA, including its regulations; there is no private right of action. ... Second, the Policy does not incorporate or impose on Merchants obligations under the UIPA or its regulations. Absent the incorporation of these obligations into the Policy, their potential violation does not breach the Policy.

Section 146.7(e) requires insurers to notify claimants in writing about applicable limitations or contractual time limits and to give specified advance notice to unrepresented first-party and third-party claimants.

Cutting Edge Tree Professionals, LLC v. State Farm Fire Claims Company · filed 2024-01-04(e)

However, this provision is plainly inapplicable when a plaintiff is represented by counsel, as is the case here. By way of example, attached as exhibits to Plaintiff’s Complaint are correspondence from Plaintiff’s attorney to State Farm dated October 19, 2022 and October 27, 2022, whereby counsel for Plaintiff advised Defendant that it had until October 31, 2022 to change course or Plaintiff would file suit. Thus, there is no evidence that State Farm violated 31 Pa. Code § 146.7(e).

Section 146.7(c)(1)'s notice duty applies to the first-party claimant, so a medical provider that is not the policy purchaser or claimant cannot invoke the regulation as the claimant.

Freedom Medical Supply v. Allstate Fire · filed 2016-11-15(c)(1)

Initially, the regulations cited by Freedom Medical that were purportedly violated only apply to claimants. ... 31 Pa. Code § 146.7(c)(1) (stating that “[i]f the insurer needs more time to determine whether a first-party claim should be accepted or denied, it shall so notify the first-party claimant within 15 working days after receipt of the proofs of loss giving the reasons more time is needed. …”) (emphasis added); ... Santos, the purchaser of the insurance policy with Allstate, not Freedom Medical, is the claimant.

Section 146.7(a)(1) requires a denial to reference the specific policy provision only when the insurer bases the denial on that provision; the court concluded the rescission here was based on Pennsylvania law concerning material misrepresentations, not policy language.

HORVATH v. GLOBE LIFE AND ACCIDENT INSURANCE COMPANY · filed 2019-08-27(a)(1)

In terms of Section 146.7(a)(1), the Court understands Plaintiff to be arguing that Defendant should have quoted the policy provision upon which it based the rescission in the rescission letter. But Defendant does not appear to have based the rescission on the policy language. Instead, as stated in the rescission letter, Defendant based the rescission on Pennsylvania law regarding rescission for material misrepresentations.