The Mission of the Market Conduct Division is to assist the Commissioner in proactively protecting West Virginia consumers by identifying non-compliant business practices of regulated entities through examinations and data analysis.
The Market Conduct Section conducts its mission through four primary functions:
1. Conduct Market Conduct Examinations and other formal regulatory inquiries;
2. Performing Market Analysis on insurers licensed to do business in West Virginia;
3. Monitoring self-insured employers that are self-administering their workers' compensation claims in accordance to established statutes and rules; and,
4. Recommend approval of External (Independent) Review Organizations.
For questions, please contact our Office at (304) 558-0401, or send us a fax at (304) 558-1362.
Market Conduct Examinations
W. Va. Code §33-2-9 requires the Insurance Commissioner to “thoroughly examine the financial conditions, and business affairs” of all insurers licensed to transact business in the State of West Virginia every five years. The Insurance Commissioner may accept company examinations from other states provided that the state conducting the examination is accredited by the National Association of Insurance Commissioners (NAIC). The code section further grants the Insurance Commissioner the authority to examine other entities which transact the business of insurance: these entities include but are not limited to agencies, third party administrators, and insurance adjusting firms; examination of these types of entices are conducted solely at the Commissioner’s discretion. Examinations may be conducted on-site or through analysis of data which the company submits to the regulator.
The Market Conduct Section examines insurance companies to confirm they are complying with consumer oriented insurance laws of the State of West Virginia. Market Conduct Examinations are a proactive regulatory tool. While some market conduct examinations are initiated pursuant to alleged patterns or practices reported to the Insurance Commissioner, many examinations are the result of a statutory requirement that the Commissioner routinely examine all domestic insurers every five years. Therefore, the mere fact that a company is being examined is not in itself an indicator that the company has deficient business practices. Market Conduct Examiners will investigate for possible violations of insurance statutes and rules contained within Chapters 23 and 33 of the West Virginia Code and Titles 85 and 114 of the West Virginia Code of State Rules. Examples of areas reviewed include timeliness of the Company’s claims payments, adherence to the Company’s filed rates, and fairness of the Company’s underwriting practices. Depending upon the findings and recommendations of the examination, the Insurance Commissioner may order the company to take corrective action, make restitution to consumers, or assess a fine or other sanctions.
There are three basic types of Market Conduct Examinations:
Comprehensive Examinations: As the name suggests, comprehensive examinations cover nearly all of an insurers operations with the exception of financial operations. The basic areas reviewed are as follows:
- Operations and Management
- Complaint Handling
- Producer Licensing
- Policyholder Services
- Underwriting and Rating
Comprehensive examinations on health insurers include the following additional areas of review:
- Network Adequacy
- Provider Credentialing
- Grievance Procedures
In general, comprehensive examinations are conducted on West Virginia domestic insurers only and are routine in nature. Comprehensive examinations may involve the review from 38 to 125 standards selected from the NAIC Market Regulation Handbook (see appendices A & B).
Targeted Examinations: This type of examination focuses on a specific area of concern (i.e.: a line of business or a business practice, such as underwriting, marketing or claims). A common example of where a target exam is frequently used involves third party complaints alleging some type of unfair trade practice. These exams may be called at any time, with or without notice to the insurer as circumstances dictate.
Multi-State Collaborative Examinations or Actions: Certain behavior conducted by an insurer is unique based on variable factors (like a state’s rules and regulations). Many of the defined unfair trade acts and practices, as well as unfair claims acts and practices, are similar from jurisdiction to jurisdiction. When utilized properly, a collaborative action can reduce the scope, duration and expense of additional examinations. When several jurisdictions have a joint interest in the market conduct of a company, they might find their collective concerns are best met through a cooperative effort. The participating states may agree to prepare a single joint report or prepare separate reports for each jurisdiction.
Use the following links to view West Virginia market conduct examinations completed since 2007 by date the reports were adopted.