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Mission of the Market Conduct Division
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
  • Claims
 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.
Market Analysis
Market Analysis is the collection and analysis of a broad range of company and market information to help identify market conduct problems. The Market Conduct Section has adopted and will integrate market analysis standards and procedures into its current market regulatory functions. A key aspect of Market Analysis is the utilization of Market Analysis profile reports available to state regulators for use in researching companies. These reports can be used for general inquiries, developing questions to ask companies, interrogatories, and investigations. Market Analysis will enable the Market Conduct Examiners to identify general market disruptions and important market conduct problems as early as possible and to eliminate and/or limit the harm to consumers. In addition, it will provide a framework for collaboration among states and with federal regulators regarding identification of market conduct issues and market conduct regulation. 
 
Monitoring Self-Administration of Workers’ Compensation Claims performed on behalf of Self-Insured Employers
 
Effective August 16, 2008, the Claims Audit function of the Self-Insured Unit was transferred to the Market Conduct Unit.
 
The goals to be achieved by the Self-Insurance Claims’ Examination process are:
 
  • to ensure that the employer has complied with the applicable laws and regulations;
  • to ensure that injured employees receive timely and accurate delivery of the Workers’ Compensation benefits to which they are entitled; 
  • to provide the third party administrator with information that will enable them to assess and evaluate their claims administration practices;
  • to identify employers which have reported inaccurate or untimely information to the Insurance Commissioner via EDI;
  • to identify those entities who repeatedly violate applicable laws and regulations; and,
  • to identify issues that may require the modification of current regulatory and statutory requirements.
At the conclusion of the audit, an exit conference is conducted to go over the results of the review.  The examiner then composes a letter to the self-insured employer and the third party administrator that identifies the findings. Any findings resulting from a failure by the self-insured to pay any benefit, or violation of any Statute or Rule with enough frequency to be considered a general business practice may result in an order directing corrective action. Penalties may also be assessed based on the results of the examination. The letter is also mailed to the employer and third party administrator but due to the large size of the examination program, a paper copy is not included in the mailing. The examiner maintains a log of outstanding findings to ensure the employer submits the required proof that the errors have been corrected. The examination findings and the employer’s compliance with the requested corrections may be included in the annual review.
 

ERO (External Review Organizations) /IRO (Independent Review Organizations)

The Market Conduct division is responsible for the review of the applications that are provided by EROs/IROs, which are independent review companies that review the consumer’s grievance or appeal of an adverse benefit determination made by Insurance Companies and Health Maintenance Organizations.

HMOs other  Major Medical Carriers

Effective January 1, 2012, the external review process for all issuers, including HMOs, is governed by the federal requirements set forth in HHS's Technical Release 2011-02 issued June 22, 2011 http://cciio.cms.gov/resources/files/appeals_srg_update.pdf.pdf 

 

Long Term Care

Recent amendments to West Virginia’s long term rule, W. Va. Code St. R. §114-3 added a provision granting an insured the right to appeal an insurer’s adverse benefit trigger determination to a certified independent review organization (IRO). To be certified, an IRO must submit an application to the West Virginia Offices of the Insurance Commissioner (WVOIC). Certification must be renewed every three years unless otherwise subjected to additional review, suspension, or revocation by the WVOIC. 

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