reglab/statecodes huggingface dataset:
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-12 - Individual Accident And Sickness Insurance Minimum Standards › Appendix J

Current through Register Vol. XLI, No. 28, July 12, 2024
NOTICE TO APPLICANT REGARDING REPLACEMENT
OF ACCIDENT AND SICKNESS INSURANCE
According to [your application] [information you have furnished],
				  you intend to lapse or otherwise terminate existing accident and sickness insurance
				  and replace it with a policy to be issued by [insert company name] Insurance
				  Company. For your own information and protection, you should be aware of and
				  seriously consider certain factors which may affect the insurance protection
				  available to you under the new policy.
(1) Health conditions which you may presently have (preexisting
				  conditions) may not be immediately or fully covered under the new policy. This could
				  result in denial or delay of a claim for benefits present under the new policy,
				  whereas a similar claim might have been payable under your present policy.
(2) You may wish to secure the advice of your present insurer or
				  its agent regarding the proposed replacement of your present policy. This is not
				  only your right, but it is also in your best interest to make sure you understand
				  all the relevant factors involved in replacing your present coverage.
(3) If, after due consideration, you still wish to terminate your
				  present policy and replace it with new coverage, be certain to truthfully and
				  completely answer all questions on the application concerning your medical/health
				  history. Failure to include all material medical information on an application may
				  provide a basis for the insurer to deny any future claims and to refund your premium
				  as though your policy had never been in force. After the application has been
				  completed and before you sign it, reread it carefully to be certain that all
				  information has been properly recorded.
The above "Notice to Applicant" was delivered to me on:
____________________________
(Date)
____________________________
(Applicant's Signature)
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-12 - Individual Accident And Sickness Insurance Minimum Standards › Appendix K

Current through Register Vol. XLI, No. 28, July 12, 2024
NOTICE TO APPLICANT REGARDING REPLACEMENT
OF ACCIDENT AND SICKNESS INSURANCE
According to [your application] [information you have furnished],
				  you intend to lapse or otherwise terminate existing accident and sickness insurance
				  and replace it with the policy delivered herewith issued by [insert company name]
				  Insurance Company. Your new policy provides ten days within which you may decide
				  without cost whether you desire to keep the policy. For your own information and
				  protection, you should be aware of and seriously consider certain factors which may
				  affect the insurance protection available to you under the new policy.
(1) Health conditions which you may presently have (preexisting
				  conditions) may not be immediately or fully covered under the new policy. This could
				  result in denial or delay of a claim for benefits under the new policy, whereas a
				  similar claim might have been payable under your present policy.
(2) You may wish to secure the advice of your present insurer or
				  its agent regarding the proposed replacement of your present policy. This is not
				  only your right, but it is also in your best interest to make sure you understand
				  all the relevant factors involved in replacing your present coverage.
(3) [To be included only if the application is attached to the
				  policy.] If, after due consideration, you still wish to terminate your present
				  policy and replace it with new coverage, read the copy of the application attached
				  to your new policy and be sure that all questions are answered fully and correctly.
				  Omissions or misstatements in the application could cause an otherwise valid claim
				  to be denied. Carefully check the application and write to [insert company name and
				  address] within ten days if any information is not correct and complete, or if any
				  past medical history has been left out of the application.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-13 - Rules Of Practice And Procedure For Hearings Before The WV Insurance Commissioner › Section 114-13-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- The
				purpose of this rule is to set forth rules of practice and procedure to be followed
				in connection with administrative hearings conducted by the Insurance Commissioner,
				or his or her duly appointed representative, pursuant to authority granted the
				commissioner in W. Va. Code §
									33-2-13. These rules are
				intended to meet the requirements of W. Va. Code §
									29A-5-1
				(State Administrative Procedures). These rules shall be applied in connection with
				any hearing conducted by the commissioner, or his or her representatives, to
				accomplish any purpose deemed necessary by the commissioner for the performance of
				his or her duties. This rule does not apply to hearings held under the "Insurance
				Tax Procedures Act," W. Va. Code §§
									33-43-1 et seq., or
				investigative hearings held under W. Va. Code §
									33-2-9,
				which are subject to the requirements in subsection 33-2-9(k).
1.2. Authority. -- W. Va. Code §§
									33-2-10 and
				29A-3-3.
1.3. Filing Date. -- September 29, 2003.
1.4. Effective Date. -- October 29,
				2003.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-13 - Rules Of Practice And Procedure For Hearings Before The WV Insurance Commissioner › Section 114-13-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
As used in this regulation:
2.1. "Commissioner" means the Insurance
				Commissioner of West Virginia.
2.2.
				"Hearings Examiner" means the person conducting a hearing by the authority of the
				Insurance Commissioner.
2.3. "Hearing"
				means any proceeding held under authority granted the commissioner by law and
				conducted in accordance with the rules set forth in this regulation. A hearing may
				be designated by the commissioner as either a Category (A) or Category (B)
				proceeding.
2.4. "Category (A) Hearing"
				means a hearing the purpose of which is:
a. To
				determine whether the license of an individual insurance producer, insurance agency,
				excess line broker or solicitor is to be revoked, suspended, nonrenewed, or placed
				on probation and/or a penalty levied; or
b. To determine whether the license of an insurer
				is to be revoked, suspended or nonrenewed or a fine levied in lieu thereof. For the
				purpose of this regulation, "Insurer" shall be deemed to include any legal entity
				holding a license to make and issue contracts of insurance.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-13 - Rules Of Practice And Procedure For Hearings Before The WV Insurance Commissioner › Section 114-13-3 - Hearings

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. General. -- The
				commissioner may call and hold hearings for any purpose deemed necessary by him or
				her for the performance of his or her duties. The commissioner shall hold hearings
				when required by law or upon a written demand therefore by a person claiming to be
				aggrieved by any act or failure to act by the commissioner or by any rule or order
				of the commissioner.
3.2. Demand for
				hearing; form required. -- Any written demand filed pursuant to subsection 3.1 of
				this section by a person claiming to be aggrieved shall specify the grounds to be
				relied upon as basis for the relief to be requested at such hearing.
3.3. Hearing on written demand. -- When the
				commissioner is presented with a demand for a hearing as described in subsections
				3.1 and 3.2 of this section, he or she shall conduct a hearing within forty-five
				(45) days of receipt by him or her of such written demand, unless postponed to a
				later date by mutual agreement. However, if the commissioner shall determine that
				the hearing demanded:
a. Would involve an exercise
				of authority in excess of that available to him or her under law; or
b. Would serve no useful purpose, the commissioner
				shall, within forty-five (45) days of receipt of such demand, enter an order
				refusing to grant the hearing as requested, incorporating therein his or her reasons
				for such refusal. Appeal may be taken from such order as provided in W. Va. Code
				§
										33-2-14.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-13 - Rules Of Practice And Procedure For Hearings Before The WV Insurance Commissioner › Section 114-13-4 - Conferences; Informal Disposition of Cases

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. Conferences. -- At any time prior to the
				hearing or thereafter, the commissioner or a person conducting the hearing by his or
				her authority, may hold conferences:
a. To dispose
				of procedural requests or similar matters;
b. To simplify or settle issues by consent of the
				parties; or
c. To provide for the
				informal disposition of cases by stipulation, agreed settlement or consent order.
The commissioner may cause such conferences to be held on his or
				  her motion or by request of a party.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-13 - Rules Of Practice And Procedure For Hearings Before The WV Insurance Commissioner › Section 114-13-6 - Conduct of Hearings

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. General. -- An
				opportunity shall be afforded all parties to present evidence and argument with
				respect to the matters and issues involved. All hearings shall be conducted in an
				impartial manner. Every party shall have the right of cross-examination of witnesses
				who testify and shall have the right to submit rebuttal evidence. Persons directly
				affected by the hearing may appear in person or by counsel, may be present during
				the giving of all evidence, and shall have a reasonable opportunity to inspect all
				documentary evidence, to examine witnesses, to present relevant evidence, and to
				have subpoenas issued by the commissioner to compel attendance of witnesses and
				production of evidence.
6.2. Who shall
				conduct. -- Hearings shall be conducted by the commissioner or the person designated
				by him or her to be the Hearings Examiner. The person conducting the hearing shall
				have the power to:
a. Administer oaths and
				affirmations;
b. Rule upon offers of
				proof and receive relevant evidence;
c.
				Regulate the course of the hearings;
d.
				Hold conferences for the settlement or simplification of the issues by consent of
				the parties; and e. Dispose of procedural requests or similar matters.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-13 - Rules Of Practice And Procedure For Hearings Before The WV Insurance Commissioner › Section 114-13-7 - Record; Transcript; When Required

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. Record; transcript; when required. -- All of
				the testimony and evidence taken at any hearing before the commissioner shall be
				reported by stenographic notes and characters or by mechanical means. The
				commissioner shall prepare an official record of each hearing, to include reported
				testimony, exhibits, notices of hearing, answers, stipulations, motions, orders and
				staff memoranda and data used in consideration of the case, but it shall not be
				necessary to transcribe the reported testimony unless:
a. Requested in writing by a person directly
				affected by a hearing at the expense of such person;
b. Required for purposes of rehearing;
				or
c. Required for judicial
				review.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-13 - Rules Of Practice And Procedure For Hearings Before The WV Insurance Commissioner › Section 114-13-8 - Orders

Current through Register Vol. XLI, No. 28, July 12, 2024
8.1. Content. -- Every
				final order entered by the commissioner, following a hearing conducted pursuant to
				these rules, shall be made pursuant to the provisions of W. Va. Code §
									29A-5-3. Such
				orders shall be entered within forty-five (45) days following the completion of a
				hearing unless the time be extended by mutual consent. For the purposes of this
				section, a hearing shall be deemed completed at such time as the commissioner has
				concluded the taking of evidence and has received any briefs, memoranda, or motions,
				which may have been submitted by parties following the hearing.
8.2. Service. -- Copies of orders shall be
				delivered to all parties by certified mail, return receipt requested.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-13 - Rules Of Practice And Procedure For Hearings Before The WV Insurance Commissioner › Section 114-13-9 - Severability

Current through Register Vol. XLI, No. 28, July 12, 2024
9.1. Partial invalidity.
				-- If any provision of this regulation shall be held invalid, the remainder of the
				regulation shall not be affected thereby.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-14 - Unfair Trade Practices › Section 114-14-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope.
a. The purpose of this rule is to define certain
				practices in this state which constitute unfair methods of competition or unfair or
				deceptive acts or practices and to establish certain minimum standards and methods
				of settlements of both first-party and third-party claims.
b. This rule does not prohibit the use of
				additional methods above the minimum which are not in violation of this rule or any
				other West Virginia statute or rule.
c.
				This rule applies to all persons and to all insurance policies and insurance
				contracts except Workers' Compensation Insurance.
d. This rule is not exclusive, and other acts, not
				herein specified, may also constitute unfair claims settlement practices.
e. Nothing in this rule creates or recognizes,
				either explicitly or impliedly, any new or different cause of action not otherwise
				recognized by law.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-14 - Unfair Trade Practices › Section 114-14-3 - File And Record Documentation

Current through Register Vol. XLI, No. 28, July 12, 2024
The insurer's claim files shall be subject to examination by the
				  Commissioner or by his or her duly appointed designees. Such files shall contain all
				  notes and work papers pertaining to the claim in such detail that pertinent events
				  and the dates of such events can be reconstructed. All communications and
				  transactions emanating from or received by the insurer shall be dated by the
				  insurer. A notation of the substance and date of all oral communications shall be
				  contained in the claim file. Insurers shall either make a notation in the file or
				  retain a copy of all forms mailed to claimants.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-14 - Unfair Trade Practices › Section 114-14-4 - Representation of Policy Provisions and Benefits

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. Failure to disclose pertinent policy
				provisions. -- No person may knowingly fail to fully disclose to first-party
				claimants all pertinent benefits, coverages or other provisions of an insurance
				policy or insurance contract under which a claim is presented.
4.2. Concealment of pertinent policy provisions.
				-- No person may knowingly conceal from first-party claimants benefits, coverages or
				other provisions of any insurance policy or insurance contract when such benefits,
				coverages or other provisions are pertinent to a claim.
4.3. Coercive statements. -- No person may make
				statements which indicate that the rights of a claimant may be impaired if a form or
				release is not completed within a given period of time unless the statement is given
				for the purpose of notifying the claimant of the provisions of a statute of
				limitation or of a policy or contract time limit.
4.4. Time limit for notification of claim. --
				Except where a time limit is specified by statute or legislative rule, no insurer
				may require a first-party claimant to give notification of a claim or proof of claim
				within a specified time.
4.5. Releases.
a. No person may ask a first-party claimant to
				sign a release that extends beyond the subject matter which gave rise to the claim
				payment.
b. No insurer may issue any
				check or draft, in partial settlement of a loss or claim under a specific coverage,
				that contains language which releases the insurer or its insured from its total
				liability.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-14 - Unfair Trade Practices › Section 114-14-5 - Standards For The Acknowledgment Of Pertinent Communications

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. Acknowledgment of notices of claims. -- Every
				insurer, upon receiving notification of a claim shall, within fifteen (15) working
				days, acknowledge the receipt of such notice unless full payment is made within such
				period of time. If an acknowledgment is made by means other than writing, an
				appropriate notation of such acknowledgment shall be made in the claim file of the
				insurer and dated. Notification given to an agent of an insurer shall be
				notification to the insurer.
5.2. Answer
				of inquiries from Insurance Commissioner. -- Every insurer, producer or other
				licensee, upon receipt of any inquiry other than a notice of third-party
				administrative complaint from the Insurance Commissioner shall, within fifteen (15)
				working days of the date appearing on the inquiry, furnish the Commissioner with a
				complete written response to the inquiry. A "complete written response" addresses
				all issues raised by the claimant or the Commissioner and includes copies of any
				documentation requested. This subsection is not intended to permit delay in
				responding to inquiries by the Commissioner or his or her staff in conjunction with
				a scheduled examination on the insurer's premises.
5.3. Replies to other pertinent communications. --
				A reply shall be made within fifteen (15) working days of receipt by the insurer to
				all other pertinent communications from a claimant which reasonably suggest that a
				response is expected.
5.4. Provisions of
				assistance to first-party claimants. -- Every insurer, upon receiving notification
				of a claim, shall promptly provide necessary claim forms, instructions, and
				reasonable assistance so that first-party claimants can comply with the policy
				conditions and the insurer's reasonable requirements. Compliance with this
				subsection within fifteen (15) working days of notification of a claim constitutes
				compliance with subsection 5.1. of this section.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-14 - Unfair Trade Practices › Section 114-14-6 - Standards For Prompt Investigations And Fair And Equitable Settlements Applicable To All Insurers

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. Investigation
				of claims. -- Every insurer shall promptly conduct and diligently pursue a thorough,
				fair and objective investigation and may not unreasonably delay resolution by
				persisting in seeking information not reasonably required for or material to the
				resolution of a claim dispute. This section is not intended to conflict with the
				statutory requirements of the Medical Professional Liability Act, W. Va. Code
				§§
									55-7B-1
				to 11, as the same relate to the assertion and investigation of medical professional
				liability claims.
6.2. Establishment of
				investigatory procedures. --
a. Every insurer
				shall establish procedures to commence an investigation of any claim filed by a
				claimant, or by a claimant's authorized representative, within fifteen (15) working
				days of receipt of notice of claim.
b.
				Every insurer shall provide to every first-party claimant, or to the claimant's
				authorized representative, a notification of all items, statements and forms, if
				any, which the insurer reasonably believes will be required of such claimant, within
				fifteen (15) working days of receiving notice of the claim.
c. A claim filed with an agent of an insurer shall
				be deemed to have been filed with the insurer unless, consistent with law or
				contract, such agent promptly provides written notification to the person filing the
				claim that the agent is not authorized to receive notices of claim.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-14 - Unfair Trade Practices › Section 114-14-8 - Training and Certification

Current through Register Vol. XLI, No. 28, July 12, 2024
Within ninety (90) days of the effective date of this rule, every
				  insurer shall adopt and communicate to all its claims agents written standards for
				  the prompt investigation and processing of claims.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-14 - Unfair Trade Practices › Section 114-14-9 - Separability

Current through Register Vol. XLI, No. 28, July 12, 2024
If any provision of this rule is held invalid, the remainder of
				  the rule shall not be affected thereby.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-14 - Unfair Trade Practices › Section 114-14-10 - Penalty For Violation Of Any Provision Of This Regulation

Current through Register Vol. XLI, No. 28, July 12, 2024
Any person who fails to comply with any provision of this
				  regulation shall, after notice and hearing, be found to be transacting insurance in
				  an illegal, improper or unjust manner. The Commissioner may, pursuant to W. Va. Code
				  §§
									33-3-11,
				  33-11-6,
				  33-11-7,
				  33-11-8
				  and
				  33-12-25,
				  refuse to renew, or may revoke or suspend the license of any such person or, in lieu
				  thereof, the Commissioner may, at his or her discretion, order such person to pay to
				  the State of West Virginia a penalty in a sum not to exceed that imposed by said
				  sections of said code, and the Commissioner may, pursuant to W. Va. Code §
									33-2-11,
				  order such person to discontinue such illegal, improper or unjust transaction of
				  insurance and to adjust and pay obligations as they become due.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-15 - Examiners And Examinations › Section 114-15-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- This
				legislative rule establishes:
a. Standards for the
				compensation, qualifications and classification of persons who conduct or
				participate in any analysis, review or examination provided for in W. Va. Code
				§
										33-2-9;
				and
b. Standards for retention of
				records and documents that the commissioner may require to be produced by an insurer
				in connection with any analysis, review or examination provided for in W. Va. Code
				§
										33-2-9.
c. This rule applies to all insurers authorized to
				transact insurance in this state by the commissioner, health maintenance
				organizations, hospital, medical, dental and health service corporations, health
				care corporations, fraternal benefit societies, and prepaid limited health service
				organizations.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-15 - Examiners And Examinations › Section 114-15-3 - Examination, Analysis and Review Funding

Current through Register Vol. XLI, No. 28, July 12, 2024
3.1. Every entity subject to the provisions of W.
				Va. Code §
									33-2-9
				shall remit the examination assessment fee specified by the code or as increased by
				the commissioner on or before the first day of July of each year.
3.2. Every entity subject to the provisions of W.
				Va. Code §
									33-2-9
				shall remit any additional examination assessment fee ordered by the commissioner on
				or before the date specified by the order.
3.3. The monies collected by the commissioner from
				the examination assessment fee and any additional examination assessment fee shall
				be deposited as specified in W. Va. Code §
									33-2-9.
				The monies deposited into the commissioner's examination revolving fund may be used
				for any of the following:
a. Salaries and expenses
				of the insurance commissioner's accredited examiners as specified in this rule for
				any activities conducted pursuant to W. Va. Code §
										33-2-9
				or this rule;
b. Salaries and/or
				expenses of the insurance commissioner's special deputies or other employees for
				activities conducted pursuant to W. Va. Code §
										33-2-9
				or this rule;
c. Salaries, contract
				rates, fees and/or expenses of other individuals or entities for activities
				conducted pursuant to W. Va. Code §
										33-2-9
				or this rule; and
d. Equipment,
				supplies, travel, education, and training and other incidental expenses for the
				commissioner, his or her deputies, other employees and accredited examiners as
				considered necessary by the commissioner for the performance of the duties and
				activities conducted pursuant to W. Va. Code §
										33-2-9
				or this rule.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-15 - Examiners And Examinations › Section 114-15-4 - Examination, Analysis, Review Activities and Record Retention Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
4.1. Examination,
				analysis and review activities shall include the following as they relate to the
				operation of entities, individuals or persons subject to the provisions of W. Va.
				Code §
									33-2-9:
a. Examination of the financial condition or
				market conduct practices of the entity, individual or person;
b. On-site analysis or review of any practice or
				condition affecting the entity, individual or person; and c. Review of any
				statements, reports, or reviews of an entity, individual or person's financial
				condition, performance or market conduct practices including the review or
				development of any forecasts or projections or any type of filing made or intended
				to be made with the insurance commissioner. This review shall include but not be
				limited to the review or investigation of any audited financial report, compilation
				or review performed by a certified public accountant, actuarial statement or
				certification, documents submitted in application for licensure or registration in
				the state, or other matters or materials deemed necessary by the commissioner to
				fulfill his or her statutory obligations.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-15 - Examiners And Examinations › Section 114-15-5 - Contracts for Services and Bond Requirements for Other Individuals

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. The commissioner
				may, as he or she considers necessary, retain any other individual or entity, as
				defined in subsection 2.17 of this rule, to conduct, supervise, or participate in
				any examination, analysis or review as provided in W. Va. Code §
									33-2-9,
				or this rule.
5.2. Any contract between
				the commissioner and any other individual or entity, whose services are retained
				pursuant to this section, is specifically exempt from the competitive bidding
				requirements contained in W. Va. Code §
									5A-3-1
				et seq.
5.3. The commissioner may, as he
				or she considers necessary, require any other individual or entity, whose services
				are retained pursuant to this section, to furnish an appropriate bond prior to
				conducting, supervising, or participating in any examination, analysis or review as
				provided in W. Va. Code §
									33-2-9
				or this rule, as follows:
a. The bond shall be in
				an amount which in the commissioner's discretion is sufficient to complete the
				examination, analysis or review, but in no event shall be in an amount of less than
				ten thousand dollars ($10,000.00).
b.
				Should the commissioner require any other individual or entity, whose services are
				retained pursuant to this section, to provide a bond, it shall be issued by a
				company licensed to transact surety insurance in the state of West Virginia as
				provided in W. Va. Code §
										33-19-1
				and which has received at least an A rating by A.M. Best Company, Inc. in the year
				immediately preceding the date of the bond's issuance.
c. Proof of payment for and issuance of the bond
				shall be submitted to the commissioner prior to commencement of any examination,
				analysis or review by any other individual or entity whose services are retained
				pursuant to this section.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-15 - Examiners And Examinations › Section 114-15-6 - Compensation and Accrued Time of Accredited Examiners

Current through Register Vol. XLI, No. 28, July 12, 2024
6.1. Subject to the commissioner's approval,
				insurance company examiner supervisors and market conduct examiner supervisors shall
				receive the salary recommended for insurance examiners in-charge by the Market
				Regulation Handbook or Financial Condition Examiners Handbook of the National
				Association of Insurance Commissioners. Subject to the commissioner's approval,
				insurance company examiners and market conduct examiners shall receive the salary
				recommended for insurance company examiners by the Market Regulation Handbook or
				Financial Condition Examiners Handbook of the National Association of Insurance
				Commissioners.
6.2. An examiner's salary
				shall be calculated based upon a five-day work week.
6.3. Examiners shall accrue and use annual leave
				and sick leave at the rates and in the manner established by current West Virginia
				Division of Personnel rules for state employees or by such other equivalent method
				as may be adopted by the state of West Virginia, and as supplemented by agency
				policies regarding use of annual and sick leave established by the commissioner.
a. On any West Virginia state or national holiday
				that a company being examined chooses to remain open and an examiner chooses to
				work, the examiner shall be properly compensated.
b. Examiners shall not be reimbursed for travel or
				living expenses for any day authorized as annual leave.
c. Examiners shall continue to be reimbursed for
				living expenses during times of sick leave as long as the examiner remains at his or
				her on-site lodging during the illness.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-15 - Examiners And Examinations › Section 114-15-7 - Travel and Living Expenses

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. Travel by
				examiners in connection with activities conducted pursuant to W. Va. Code §
									33-2-9
				or this rule shall not be undertaken unless authorized by the commissioner or his or
				her designee. Travel expenses are subject to the following limitations:
a. All travel shall be by automobile unless
				otherwise authorized by the commissioner or his or her designee.
1. Examiners shall be compensated for the actual
				mileage traveled and other incidental expenses for in-state and out-of-state travel
				as allowed by the Governor's travel rules.
2. When an automobile is used, and the distance to
				an examination or to an assignment is four hundred (400) miles or more, the distance
				traveled per day shall not be less than four hundred (400) miles per day.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-15 - Examiners And Examinations › Section 114-15-8 - Examiner Reporting Requirements

Current through Register Vol. XLI, No. 28, July 12, 2024
8.1. The
				examiner in charge shall prepare an "examiner's semimonthly days worked report" to
				be submitted on a form prescribed by the commissioner. The form shall be submitted
				to the commissioner within three (3) days of the end of each semimonthly pay period.
				The report shall contain the following information:
a. The period of time the report covers;
b. The name of entity, individual or person that
				is being examined and their normal hours of operation;
c. The mailing address and street address,
				including county, of the business location of the entity being examined, and the
				mailing address and street address of the examiner's on-site lodging;
d. The telephone number(s) and extension(s) where
				the examiner can be reached at all times;
e. The domiciliary state, if the examination is
				being performed on a non-domestic entity;
f. A listing of any other individual or entity
				participating in the assignment and their domicile or zone representation, if
				applicable;
g. A description of the
				phases of the examination or assignment that the examiner worked on during the
				reporting period;
h. Comments on any
				unusual or controversial items;
i. The
				tentative closing date of the assignment;
j. A schedule of each of the days in the reporting
				period and the examiner's status on that day, to include the total of days
				designated as work days, annual days, sick days and expense days; and k. The name
				and signature of the examiner in charge completing the report and a statement that
				the information provided is true and correct.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-17 - Medicare Supplement Insurance Coverage › Section 114-17-1 - General

Current through Register Vol. XLI, No. 28, July 12, 2024
1.1. Scope. -- The
				purpose of this regulation is to establish certain minimum standards and provide
				reasonable standardization and simplification of terms and coverages for policies or
				subscriber contracts of accident and sickness insurance which are issued to persons
				eligible for Medicare by reason of age and which are designed to supplement Medicare
				or which are advertised, marketed or otherwise purported to be a supplement to
				Medicare, to eliminate provisions contained in any policy or contract sold to a
				person eligible for Medicare by reason of age which may be misleading or confusing,
				to establish certain loss ratio requirements and provide for full disclosure in the
				sale of such coverages.
(a) This regulation shall
				apply to:
(1) All individual Medicare Supplement
				or Limited Benefit Medicare Supplement policies and subscriber contracts delivered
				or issued for delivery in this State on or after the effective date hereof,
				and
(2) All certificates issued under
				group Medicare Supplement or Limited Benefit Medicare Supplement policies or
				subscriber contracts, which policies or contracts have been delivered or issued for
				delivery in this State, and
(3) Where
				applicable, all policies or contracts purporting to offer medical or surgical
				coverage which are delivered or issued for delivery in this State to persons
				eligible for Medicare by reason of age, including hospital confinement indemnity
				coverage, nursing home coverage and specified disease coverage sold to such
				persons.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-17 - Medicare Supplement Insurance Coverage › Section 114-17-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
2.1. "Applicant" shall
				mean:
(a) In the case of an individual Medicare
				Supplement or Limited Benefit Medicare Supplement policy or subscriber contract, the
				person who seeks to contract for insurance benefits; and
(b) In the case of a group Medicare Supplement or
				Limited Benefit Medicare Supplement policy or subscriber contract, the proposed
				certificate holder.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-17 - Medicare Supplement Insurance Coverage › Section 114-17-3 - Policy Definitions and Terms

Current through Register Vol. XLI, No. 28, July 12, 2024
No Medicare Supplement or Limited Benefit Medicare Supplement
				  policy or contract delivered or issued for delivery in this State to any person
				  eligible for Medicare by reason of age shall contain definitions or terms respecting
				  the matters set forth herein unless such definitions or terms conform to the
				  requirements of this section.
3.1.
				"Medicare" shall be defined in the policy, and may be substantially defined as "The
				Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of
				1965 as Then Constituted or Later Amended," or words of similar import.
3.2. "Medicare Benefit Period or Benefit Period"
				shall not be defined as more restrictive than defined in the Medicare
				Program.
3.3. "Medicare Eligible
				Expenses" shall mean health care expenses of the kinds covered by Medicare, to the
				extent recognized as reasonable by Medicare. Payment of benefits by insurers for
				Medicare eligible expenses may be conditioned upon the same or less restrictive
				payment conditions, including determinations of medical necessity, as are applicable
				to Medicare claims.
3.4. "Preexisting
				Condition" shall not be defined more restrictively than a condition for which
				medical advice was given or treatment was recommended by or received from a
				physician within a six (6) month period preceding the effective date of
				coverage.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-17 - Medicare Supplement Insurance Coverage › Section 114-17-4 - Minimum Standards for Medicare Supplement and Limited Benefit Medicare Supplement Policies and Contracts

Current through Register Vol. XLI, No. 28, July 12, 2024
No Medicare Supplement or Limited Benefit Medicare Supplement
				  policy or contract shall be delivered or issued for delivery in this State which
				  does not meet the requirements of this section. These are minimum standards and do
				  not preclude the inclusion of other provisions or benefits in addition to, and which
				  are not inconsistent with, these standards.
4.1. General policy provisions.
(a) Limitations based on preexisting conditions
				shall not exclude coverage for more than six (6) months after the effective date of
				coverage of the insured person for a condition for which medical advice was given or
				treatment was recommended by or received from a physician within six (6) months
				before the effective date of the coverage of an insured person.
(b) Coverage shall not indemnify against losses
				resulting from sickness on a different basis than losses resulting from
				accidents.
(c) Coverage shall provide
				that benefits designed to cover cost sharing amounts under Medicare will be
				proportionally changed automatically to coincide with any changes in the applicable
				Medicare deductible amount and copayment percentage factors. Premiums may be changed
				to correspond with such changes, subject to prior approval by the Commissioner or
				the filed rates may include incremental increases which anticipate changes in
				Medicare coverage.
(d) The terms
				"Medicare Supplement," "Medigap" and words of similar import shall not be used in
				any manner to describe a policy or contract unless the policy or contract is issued
				in compliance with this regulation.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-17 - Medicare Supplement Insurance Coverage › Section 114-17-5 - Prohibited Policy Provisions

Current through Register Vol. XLI, No. 28, July 12, 2024
5.1. Excluded
				coverage by type. -- No Medicare Supplement or Limited Benefit Medicare Supplement
				policy or contract shall limit or exclude coverage by type of illness, accident,
				treatment or medical condition except as to the following, where not inconsistent
				with Medicare:
(a) Foot care in connection with
				corns, calluses, flat feet, fallen arches, weak feet, chronic strain or symptomatic
				complaints of the feet;
(b) Mental or
				emotional disorders, alcoholism and drug addiction;
(c) Illness, treatment or medical condition
				arising out of:
(1) War or act of war (whether
				declared or undeclared);
(2)
				Participation in a felony, riot or insurrections;
(3) Service in the armed forces or units auxiliary
				thereto;
(4) Suicide (sane or insane),
				attempted suicide or intentionally self-inflicted injury;
(5) Aviation.
(d) Cosmetic surgery, except that "Cosmetic
				Surgery" shall not include reconstructive surgery when such service is incidental to
				or follows surgery resulting from trauma, infection or other diseases of the
				involved part;
(e) Care in connection
				with the detection and correction by manual or mechanical means of structural
				imbalance, distortion or subluxation in the human body for purposes of removing
				nerve interference and the effects thereof, where such interference is the result of
				or related to distortion, misalignment or subluxation of or in the vertebral
				column;
(f) Treatment provided in a
				governmental hospital; benefits provided under Medicare or other governmental
				program (except Medicaid), any state or federal workers' compensation, employer's
				liability or occupational disease law or any motor vehicle no-fault law; services
				rendered by employees of hospitals, laboratories or other institutions; services
				performed by a member of the covered person's immediate family and services for
				which no charge is normally made in the absence of insurance;
(g) Dental care or treatment;
(h) Eye glasses, hearing aids and examination for
				the prescription or fitting thereof;
(i)
				Rest cures, custodial care, transportation and routine physical
				examination;
(j) Territorial
				limitations:
Provided,
That Medicare Supplement or Limited Benefit
				  Medicare Supplement policies or contracts may not contain limitations or exclusions
				  of the types included in Subdivisions (a), (e), (i) or (j) above that are more
				  restrictive than those of Medicare. Medicare Supplement or Limited Benefit Medicare
				  Supplement policies or contracts may exclude coverage for any expense to the extent
				  of any benefit available to the insured under Medicare.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-17 - Medicare Supplement Insurance Coverage › Section 114-17-7 - Loss Ratio Standards

Current through Register Vol. XLI, No. 28, July 12, 2024
7.1. Aggregate
				benefits. -- Medicare Supplement or Limited Benefit Medicare Supplement policies or
				contracts shall be expected to return to policyholders in the form of aggregate
				benefits under the policy, as estimated for the entire period for which rates are
				computed to provide coverage, on the basis of incurred claims experience and earned
				premiums for such period and in accordance with accepted actuarial principles and
				practices:
(a) In the case of individual policies
				or contracts, at least sixty percent (60%) of the aggregate amount of premiums
				collected; and
(b) In the case of group
				policies, contracts or certificates, at least seventy-five percent (75%) of the
				aggregate amount of premiums collected.
West Virginia Code of State Rules › Agency 114 - Insurance Commission › Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER › Series 114-17 - Medicare Supplement Insurance Coverage › Section 114-17-8 - Prohibited Acts or Practices

Current through Register Vol. XLI, No. 28, July 12, 2024
8.1. Solicitation or
				sale. -- No person shall engage in any unfair, deceptive, misleading or unreasonably
				confusing act or practice in the promotion, solicitation or sale of accident and
				health insurance delivered or issued for delivery in this State to persons eligible
				for Medicare by reason of age.
8.2.
				Prima facie violations. -- The following acts and practices shall be deemed prima
				facie evidence of a violation of this section:
(a)
				Any act which encourages an applicant to omit pertinent underwriting information
				from an application;
(b) Any act which
				induces a prospective insured to sign a blank or incomplete application,
				acknowledgment or form;
(c) Failure to
				disclose, during initial solicitation to a prospective insured, any affiliation with
				an insurer;
(d) Any representations,
				expressed or implied, unless specifically authorized in writing by the organization,
				of affiliation with or authorization by any civic, social or other nongovernmental
				organization;
(e) Any representation,
				expressed or implied, of affiliation with or authorization by any governmental
				agency or of access to any information from any such agency which is not generally
				available to the public;
(f) The making
				of any false or misleading statements as to the length of time an insurance policy
				or contract may or may not be available;
(g) The issuance of any policy or contract, which
				has not been submitted to and approved by the Commissioner;
(h) The sale of Medicare Supplement or Limited
				Benefit Medicare Supplement insurance to any person not eligible for
				Medicare;
(i) The sale of any accident
				and/or sickness insurance policy or contract to any person without ascertaining
				whether the person is eligible for Medicare by reason of age;
(j) The sale of any accident and sickness
				insurance policy or contract to any person who indicates eligibility for Medicare by
				reason of age, without strict adherence to the disclosure requirements of this
				regulation;
(k) Falsely answering any
				question or signing any certification in any application or form required to be
				completed by the prospective insured;
(l) Failure by an agent to deliver, within seven
				(7) business days, any policy sent to the agent for delivery to an
				applicant;
(m) The taking of an
				application, except by direct response, without inquiring and recording the reply as
				to whether the proposed insurance will duplicate any insurance then enforce;
				or
(n) Making any inquiry in such manner
				as to invite a response contrary to fact.