27 - 34 Records & Records, Continued

Confidential Materials

- All documents obtained as part of a market conduct examination are considered privileged and confidential

Time Limits to Provide Records to Examiners

- At least 30 days before the review, commissioner should give insurer notice of examination so it has enough time to prepare requested files - Insurers have 10 days to supply any additional data not originally required

Policy Record File

- Files must clearly show the policy period, basis for rating, exclusions, and exemptions

Format & Location of Files

- Insurers can store records in any medium they choose, as long as they are kept and maintained in a way that they can be given to commissioner within time limit

Licensing Records

- Insurers must keep records of their compliance with state licensing requirements

Complaint Records

- It is an unfair claims settlement practice for an insurer to fail to maintain complete records of the complaints it receives

A claim file should include at least the following items: FOR HEALTH CLAIMS

- Medical bills (including electronically submitted bills) - Health facility pre-admission certification or utilization review documentation - Copies of explanation of benefit statements

A claim file should include at least the following items: FOR ALL CLAIM TYPES:

- Notice of claim - Claim forms - Proof of loss or other form of claim submission - Correspondence with insureds and claimants or their representatives - Documentation of the claim investigation - Medical records - Copies of checks or drafts, or check numbers and amounts - All applicable notices and releases - Correspondence used to determine and conclude claim payments or denials - Claim handling logs - Any written communication - Any documented or recorded phone calls about the claim, including its investigation, payment, or denial - Any other documentation in paper or electronic format that is necessary to support claim handling activity

A claim file should include at least the following items: FOR PROPERTY AND CASUALTY

- Settlement demands - Accident reports - Police reports - Inspection reports - Supporting bills - Estimates and valuation worksheets - Notes - Contracts - Declarations pages - Certificates showing coverage under a group contract - Endorsements or riders - Work papers - Numeric identifying information for debit cards, bank cards, or other similar cards, including date of issue and amounts - Subrogation and salvage documentation - Any claim manuals or other information necessary for reviewing the claim

Claim File

- Should clearly show the inception, handling, and make-up of each claim - Must be clear and specific, so that examiner can reconstruct events and dates

Penalties

- Suspension or revocation of license or $2,500 fine for violating the above regulations

Simply put: Adjusters should keep any and all documentation relating to every claim.

All documents sent to the insurer should list the initial date that the insurer received them. The insurer should stamp the date clearly with ink, in an electronic format, or in some other manner. Unless the insurer tells the examiner otherwise in writing, the earliest date on a document will be considered the initial date of receipt

Policy Record File (in depth)

An insurer must keep a policy record file for each policy it issues. Files must clearly show the policy period, basis for rating, exclusions, and exemptions, as well as: -Information related to policy termination, including documentation of any premium refunds - Applications and accompanying records with the producer clearly noted - All declarations pages - Binders - Any guidelines, manuals, or information used to determine the rating, underwriting, policy-owner service, or claim handling - Declined underwriting and documentation supporting decisions to deny

Penalties (in depth)

Any insurer or related agent who knowingly violates these regulations may be subject to suspension or revocation of its certificate of authority or license, and could be fined up to $2,500 per violation.

Time Limits to Provide Records to Examiners (in depth)

At least 30 days before the review, the commissioner should give the insurer notice of the examination so it has enough time to prepare the requested files. Insurers have 10 days to supply any additional data that was not originally required, but is requested during the on-site examination.

Format & Location of Files (in depth)

Insurers may store records in any medium they choose (such as paper, electronic, photographic, magnetic) as long they can supply a clearly legible copy to the commissioner. Computer records should be stored and archived in a way that prohibits any alterations to records once they have been archived. Most importantly, all records should be kept and maintained in a way that they can be given to the commissioner within the required time limit.

Licensing Records (in depth)

Insurers must keep records of their compliance with state licensing requirements. Licensing records should include the status of a producer at the time of solicitation, negotiation, dates of appointments, and termination details.

Claim File (in depth)

The claim file should clearly show the inception, handling, and make-up of each claim. The claim file must be very clear and specific, so that an examiner can reconstruct important events and dates. A claim file should include at least the following items:

Confidential Materials (in depth)

The commissioner will return any original records that an insurer provided during a market conduct examination, but may choose to keep copies. All documents obtained as part of a market conduct examination are considered privileged and confidential.

Market Conduct Records Retention (in depth)

The insurance commissioner can request a market conduct examination of a licensed insurer at any time. These examinations are meant to verify the insurer is complying with all state laws and the standards outlined in the NAIC Market Regulation Handbook. The commissioner may look into company operations and management, policyholder service, marketing, licensing, underwriting, rating, complaint handling, and claims practice. Insurers must keep ALL records, files, and documents for 5 years and make them readily accessible upon the commissioner's request.

Market Conduct Examination

Verifies the insurer is complying with all state laws and the standards outlined in the NAIC Market Regulation Handbook - Insurers must keep ALL records, files, and documents for 5 years and make them readily accessible upon commissioner's request