Source: https://www.maine.gov/pfr/insurance/consent_agreements/2010-2014/12217.html
Timestamp: 2014-03-16 17:39:25
Document Index: 643478312

Matched Legal Cases: ['§ 359', '§ 359', '§ 359', '§ 359', '§ 352', '§ 352', '§ 352', '§ 402', '§ 408', '§ 359', '§ 359']

> Consent Agreements > Docket No. INS-12-217
T.H.E. INSURANCE CO. )
Docket No. INS-12-217
This Consent Agreement is entered into by and among T.H.E. Insurance Co. (the “Company”), the Maine Superintendent of Insurance (the “Superintendent”), and the Office of the Maine Attorney General (the “Attorney General”). Its purpose is to resolve, without the need for an adjudicatory proceeding, the violations of 39-A M.R.S.A. § 359(2) certified to the Superintendent by the Maine Workers’ Compensation Board (the “Board”).
The Company is organized and domiciled under the laws of the State of Louisiana, and is licensed in Maine as an insurance company under License Number PCF62863, first issued May 28, 1999. The Company handles claims arising under the Maine Workers’ Compensation Act of 1992, M.R.S.A. Title 39-A, as amended, and regulations of the Board issued thereunder (the “WCA”).
In 2009, the Board’s Monitoring Audit & Enforcement Division (the “MAE Division”) audited the records of the Company with respect to claims filed under the WCA with dates of injury in 2006–2008. This audit focused on compliance with WCA requirements for form filing, timeliness of indemnity payments, and accuracy of indemnity benefits.
On March 10, 2010, the Board issued a Compliance Audit Report detailing its findings (the “Report”). The Report’s findings relevant to questionable claims-handling techniques that violated 39-A M.R.S.A. § 359(2) included failure to file or timely file forms with the Board, incorrect dates and/or misleading information on Board forms, failure to pay initial indemnity benefits timely, failure to pay medical benefits timely, and failure to pay claims accurately. In July, 2010, the Board and the Company entered into five consent decrees, in lieu of administrative hearings, addressing the findings in the Report. In one such decree (the “Consent Decree”), the Company agreed that it had “engaged in a pattern of questionable claims-handling techniques in violation of Section 359(2)” of the WCA for the following reasons: (a) failure to file or timely file forms with the Board, (b) failure to pay benefits timely, and (c) failure to correct issues of non-compliance revealed/discussed in previous audit.
On August 3, 2010, the Board certified these findings to the Superintendent as required by 39-A M.R.S.A. § 359(2).
The Company violated 39-A M.R.S.A. § 359(2) by engaging in a pattern of questionable claims-handling techniques.
The Superintendent is required, pursuant to the Board’s August 3, 2010, certification of its findings that the Company engaged in a pattern of questionable claims-handling techniques, to take appropriate action to bring those practices to a halt.
The Company represents that it has stopped the pattern of questionable claims-handling techniques and agrees that it will not engage in any unlawful claims-handling techniques in the future.
Within thirty (30) days after executing this Agreement, the Company shall adopt, and deliver to the Superintendent for approval, with a copy to the WCB Deputy Director, MAE Division, written procedures that ensure that all claims for indemnity benefits under the WCA are paid in compliance with Maine law. At a minimum, such procedures must include plans for:
maintaining claims payment standards through ongoing staff and third-party administrator education and supervision; and
implementing adequate claim review procedures, to include monitoring the accu­racy and timeliness of WCB form filings and indemnity payments.
The Company shall audit all indemnity claims processed in the four (4) calendar quarters beginning with the quarter in which the Company executes this Agreement to measure compliance with the benchmarks in Exhibit A. Within thirty (30) days after the end of the fourth audit quarter, the Company shall deliver to the Superintendent, with a copy to the WCB Deputy Director, MAE Division, a report of the audit (the “Final Self-Audit Report”), along with a certification in the form attached as Exhibit B, attesting to the accuracy of all claims performance audit information required under this Agreement. The Company shall also deliver, upon the Superintendent’s or the WCB Deputy Director’s request, any and all work papers and documents, in any format, except for those protected by the attorney-client privilege, in its possession, custody or control, related to the Final Self-Audit Report. Within forty-five (45) days thereafter, the Superintendent may call a meeting with the Company to discuss any concerns he may have with the Company’s claims performance during the period covered by such audit report. Failure to call any such meeting shall not waive any of the Superintendent’s or the Attorney General’s rights under this Agreement. The Company shall, for the period starting January 1, 2009, and ending as of the effective date of this Agreement:
review the indemnity claims, with dates of injury on or after January 1, 1993, except those discharged under 39-A M.R.S.A. § 352, presented to the Company under the WCA, the incapacity periods, and indemnity benefits, penalties and interest originally paid thereon;
deliver to the Superintendent, with a copy to the WCB Deputy Director, MAE Division, by the date the Company must deliver the Final Self-Audit Report, an electronic spreadsheet report viewable in Microsoft Excel listing each claim so reviewed (the “Look-Back Report”). The Look-Back Report shall contain the following data, safeguarded in accordance with the WCA, for each claim: the Board number, if known;
the claimant’s Social Security number (general format/no dashes); the claimant’s last and first name (in that order); the date of injury; Company name and claim file number; the incapacity periods; the amount of indemnity originally paid; whether or not the claim was settled under 39-A M.R.S.A. § 352 (Y or N) and the date of such settlement; the amount of indemnity paid after review; the amount of penalties paid after review; the amount of interest paid after review; the amount of overpayment upon review; and the name of the person conducting the review. The Company shall deliver with the Look-Back Report a certification attesting to the accuracy of all information in the report, in the form attached as Exhibit B. This paragraph shall not apply to any claims that are subject to the audits described in paragraph 13, to any claims that have been discharged under 39-A M.R.S.A § 352, or to any claims that were previously presented to the Company or third-party administrator working on behalf of the Company that were previously audited by the Board and subse­quently corrected by the Company or third-party administrator.
did not meet or exceed on average the benefit payment and form filing bench­marks in Exhibit A during the self-audit review period described in paragraph 13, then the Company shall deliver a civil penalty of $10,000 to the Superintendent, within thirty (30) days of receiv­ing the determination; and/or
failed to correct deficiencies in indemnity payments as required by paragraph 14(c) (including payment of interest and penalties provided for in the WCA), resulting in compliance with the WCA in less than 93 percent of claims required to be reviewed pursuant to that paragraph, then the Company shall deliver a civil penalty of $5,000 to the Superintendent, within thirty (30) days of receiving the determination.
The Company agrees that (i) any civil penalties assessed in accordance with subsection (a) and/or (b) above will have resulted from its continued failure through the delivery date of either the Final Self-Adult Report or the Look-Back Report, to halt the pattern of questionable claims-handling techniques established by the Consent Decree, (ii) in declaring a civil penalty due, the Superintendent may rely on the Final Self-Audit Report and the Look-Back Report as conclusive evidence of the fact and extent of such failure, and (iii) the amount of this penalty will not limit further measures, penalties or remedies that the Superintendent or the Attorney General may impose or seek under paragraph 24 below.
16. The Company shall pay, as provided by law, the Superintendent’s reasonable costs and expenses of monitoring its compliance with, and enforcing the Company’s obligations under, this Agreement.
17. The Company shall not recoup any payments of refunds, interest, or civil penalties made under this Agreement or any costs associated with complying with this Agreement in any future rate adjustments.
18. The Company shall ensure that third-party administrators working on its behalf comply with the WCA and this Agreement. If any third-party administrator fails to comply with the WCA or this Agreement, the Company will consider removing the non-compliant third-party administrator from Company’s Maine panel of approved third-party administrators. The Company acknowledges its continued responsibility for the actions of any third-party administrator not removed from such panel.
19. The Company waives any:
objection to any action that may be taken by the Superintendent pursuant to this Agreement, including but not limited to the imposition of the penalties specified in paragraph 15 and agrees it will make no appeal from this Agreement; and
objection to the Board’s release to the Superintendent and the Attorney General of “audit working papers”, as defined in section 153 of the WCA, related to any audit of the Company and, in connection with this waiver, to the use of such papers by the Superintendent and Attorney General for purposes related to the implementation and enforcement of this Agreement. 20. The Company acknowledges that this Agreement is a public record within the meaning of 1 M.R.S.A. § 402 and will be available for public inspection and copying as provided for by 1 M.R.S.A. § 408, and will be reported to the Regulatory Information Retrieval System database at the National Association of Insurance Commissioners.
21. The Company has been advised of its right to consult with counsel and has, in fact, consulted with counsel before executing this Agreement.
22. This Agreement does not bind any person or entity not a party to this Agreement, or limit the Superintendent’s ability to seek any available legal remedy for alleged or actual violations of the WCA or the Maine Insurance Code against any Company affiliate or subsidiary not a party to this Agreement or against any entity from which the Company obtains WCA claims administrator services.
23. Nothing in this Agreement shall limit the ability of the Superintendent, in his sole and absolute discretion, in order to determine whether the Company has brought to a halt all violations of 39-A M.R.S.A. § 359(2) established by the Consent Decree, to investigate the:
a. handling of the Company’s indemnity claims having dates of injury after December 31, 2008;
b. accuracy of the self-audit quarterly review described in paragraph 13; or
c. accuracy of the indemnity claim review described in paragraph 14.
24. The purpose of the self-audit quarterly review described in paragraph 13 and the indemnity claim review described in paragraph 14 is to confirm that the violations described in the Consent Decree have ceased. Therefore, in consideration of the Company’s execution of this Agreement, the Superintendent and the Attorney General shall not pursue civil penalties, disciplinary measures or other civil or administrative sanctions, other than those agreed to herein, for violations established by the Consent Decree that continue through the period of the paragraph 13 and paragraph 14 reviews. However, the Superintendent or the Attorney General may pursue any available legal remedy, including without limitation imposition of additional civil penalties and the limitation, suspension or revocation of workers’ compensation authorities issued to the Company by the Superintendent should the Company:
a. engage in conduct that violates 39-A M.R.S.A. § 359(2) after the period of the paragraph 13 and paragraph 14 reviews; or
b. violate any provision of this Agreement other than as described in subsections (a) and (b) of paragraph 15; or
25. The effective date of this Agreement is the date entered in the Superintendent’s signature line below.
26. This Agreement may be modified only by the written consent of all parties.
T.H.E. Insurance Co.
75 xQ/12
xQ/12
Terms used but not defined in this affidavit shall have the meanings given them in the Consent Agreement entered into between T.H.E. Insurance Co. (the “Company”), the Superintendent and the Attorney General under Bureau docket number INS-12-217. I have read and understand the Consent Agreement and exhibits attached thereto.
I have read the materials attached to this affidavit. They accurately and completely summarize the information contained therein, as required by [paragraph 13/paragraph 14] of the Consent Agreement. I hold the position identified below and have obtained all necessary authority from the Company to give this affidavit on its behalf in connection with the proceedings undertaken as Bureau Docket No. INS-12-217. ______________________________________
County of _____________ Personally appeared before me on _____________, 20___, the above named ___________ __________________ and, being duly sworn, affirmed that this affidavit is based upon his or her personal knowledge and is true and correct.