West Virginia Insurance Law

Statements are deemed to be ______ if, when taken in the context of the whole presentation, they may tend to mislead or deceive a person.

misrepresentations

Transact insurance means to _____, _____ or _____ insurance.

negotiate, sell, or solicit insurance.

Insurance Commissioner: (Appointment & Duties)

* Appointed by Governor for a 6-year term * Enforces Insurance Code

_____ _____ corporations operate for the sole purpose of contracting between the public and dentists or physicians for dental services to be furnished to subscribers under terms of their contracts with the corporation.

Dental service

______ means conferring or offering advice directly to an applicant or prospective applicant of an insurance contract or the benefits, terms or conditions of the contract, in order to sell or obtain insurance from insurers for purchasers.

"Negotiate"

______ means to exchange a contract of insurance by any means, for money or its equivalent, on behalf of an insurance company.

"Sell"

_______ means attempting to sell insurance or asking or urging a person to apply for a particular kind of insurance from a particular company.

"Solicit"

The Commissioner may also require payment of a penalty up to $____ per violation, up to $____ total, unless the person knew or had reason to know he was in violation, then up to $____ per violation, $____total.

$1,000 / $10,000 $5,000 / $100,000

The Commissioner may also require insurers to pay a penalty up $____ per violation. If an insurer commits unfair claim settlement practices, the Commissioner may assess a penalty of up to $_____, as well as restitution to the claimant.

$10,000 / $250,000

An accident insurance coverage for a specific kind of accident under an AD&D policy providing at least _____ for accidental death, _____ for double dismemberment, and _____ for single dismemberment.

$1000 / $1000 / $5000

Any person required to have a license, who is found acting without a license, constitutes an unauthorized transaction of insurance and may be fined by the Commissioner a penalty not to exceed $____.

$20,000

Specified Disease Coverage: Cancer-only coverage must have a deductible not to exceed ______ and an overall benefit limit of ______ for a period of no less than three years.

$250 / $10,000

The maximum benefit paid by the West Virginia Life and Health Insurance Guaranty Association is $______ for life insurance death benefits, $______ health insurance benefits, and $______ for annuities.

$300,000 / $100,000 / $100,000

Specified Disease Coverage: The following minimum benefit standards apply to non-cancer coverages: deductible may not exceed ______ with an overall benefit limit of no less than ______ for a period of no less than two years, or no deductible and an overall benefit limit of no less that ______, payable at a rate of no less than ______ per day for a period of no less than ______ days.

$500 / $5,000 / $25,000 / $50 / 500

The minimum qualifications to be a licensed insurance producer are:

* At least 18 years of age; * Not committed any act that is grounds for denial, suspension, or revocation of a license; * Completed a prelicensing course; * Successfully passed the required license examination; * Submitted a completed application and paid all fees; * Does not intend to primarily use the license solely for obtaining insurance coverage of himself, family, property, or business; * Deemed trustworthy and competent by the Commissioner.

Insurance Commissioner: (Powers)

* Examine / investigate insurers and producers * Hold hearing - take depositions - compel witness to testify

After notice and a hearing, the Commissioner may place on probation, suspend, revoke, or refuse to renew the license of any insurer for:

* Violation of any insurance law, regulation, rule, or order of the Commissioner; * Providing incorrect, misleading, or untrue information in the license application or obtaining a license through misrepresentation or fraud; Improperly withholding or misappropriating money or property received in the course of doing insurance business; * Intentionally misrepresenting the terms of an insurance contract or application; * Conviction or pleading no contest to any felony or a misdemeanor in connection with insurance transactions; * Committing any unfair trade practice or insurance fraud; * Fraudulent, coercive, or dishonest practices demonstrating incompetence, untrustworthiness or financial irresponsibility; * Denial, suspense, or revocation of license in any other state; * Forging any document related to an insurance transaction; * Cheating on the license examination; * Knowingly accepting business from an unlicensed individual; * Failure to pay child support obligation; * Failure to pay any West Virginia taxes, fees, charges or penalties.

All policies except single-premium policies must state on the first page of the policy that the policyholder may return the policy within ____ days for a full refund of premiums and charges.

10

Investigations of claims must be thorough, fair, and prompt. Within ______ of completing the investigation, the insurer must deny the claim or offer a settlement. Settlements must be fair and reasonable, providing amounts within policy limits and in accordance with policy provisions. Denial of claims must be ______ and _____ ___ for denial.

10 days / in writing / provide grounds

The Commissioner must notify the licensee in writing if he chooses not to renew a license. The licensee may make written demand for a hearing within ________.

10 days notice

Insurers, insurance agencies and insurance producers must maintain and make records of collected information from the consumer and any other information used in making recommendations available to the Commissioner for ________ after the transaction was completed. An insurer is permitted but not required to maintain documentation on behalf of an insurance producer.

10 years

Trustee groups may be established by two or more employers in the same industry or by one or more labor unions. The policy must cover at least ____ people, and at least _____ persons from each employer/union unit.

100 / five

The Commissioner must give at least ____ days notice of the time, place and scope of matters of the hearing to all directly affected persons.

15 days

Insurers must acknowledge notification of a claim within ______ of receipt; provide all necessary claim forms within _____ of notification of a claim.

15 days / 15 days

Once a settlement is reached, the insurer must pay within _______. If an offer has a time limit, the insurer must provide notice ________ prior to expiration. It is an unfair trade practice to avoid payment under the contract.

15 days / 30 or 60 days

If the person or insurer does not comply with the order within _____ days, the Commissioner may revoke the license and assess a penalty of up to $________.

20 days / $10,000

Individual insurance producers are required to complete ______ of continuing education by providers approved by the Commissioner every ______.

24 hours / two years

Labor union group life insurance is issued to the union, who is the policyholder. The plan must have at least ____ members at the date of issue, and the amount of insurance is based on the plan not by individual selection.

25

The limiting age for dependent children in West Virginia is ______.

25

Medicare Supplement Policies must place a notice prominently printed on the first page stating that the insured person shall have the right to return the policy within ____ days of delivery and have all charges and premiums refunded if, after examination of the policy, the person is not satisfied for any reason.

30

A producer must also report to the Commissioner any criminal prosecution taken in any jurisdiction within ______ of the initial pretrial hearing.

30 days

A producer must report to the Commissioner any administrative action taken against him by any jurisdiction or governmental agency within _______ of final disposition of the matter.

30 days

If the insurer needs more than _______ for investigation, the insurer must notify the claimant of the necessary delay and the reason for the delay.

30 days

No individual may sell, solicit or negotiate annunities unless he or she is licensed as a producer for life insurance and has completed a one-time training course that must be equivalent to at least _____ continuing education credits;

4

Insurance Commissioner must hold a hearing within ____ days of a written demand, unless delayed by mutual agreement.

45 days

The Commissioner must enter an order pertaining to a hearing within ____ days after its completion unless extended by mutual consent.

45 days

An insurer must verify that each producer appointed to sell its annuity products is compliant before the producer is permitted to sell products. The insurer must maintain records supporting verification as long as the producer is appointed by the company. Records must be made available to the Commissioner upon request for _______ afterwards.

5 years

Small employer is any person or entity engaged in business in West Virginia who employs an average of ____ or less employees (but at least two eligible employees and employees).

50

Accidental death & dismemberment benefits shall be payable within __ days of form the date of accident, regardless of total disability.

90

Disability Income Protection Coverage: The elimination period is _____ for coverage providing benefits for one year or less, ______ for more than one year and less than two years, and ______ for coverage providing benefits for more than two years.

90 days / 180 days / 365 days

Each policy or certificate must contain _____. The provision must be appropriately displayed on the front page of the policy.

A renewal, continuation, or nonrenewal provision

______ is any false, maliciously critical, or derogatory communication - written or oral - that injures another's reputation, fame, or character.

Defamation

______ generally manipulates through the prospect of something desirable. An agent's subtly suggested offer to recommend the prospective client for membership in a selective club if the person purchases a particular policy is ______, for instance.

Coercion / coercive

______ ______ ______ means any offer by an insurer to persons, directly or through a third party, to effect life or health insurance coverage that enables the person to apply or enroll in the insurance on the basis of the offer directly through the insurer directly without the use of an agent, broker, or solicitor.

Direct Response Solicitation

An insurer formed under the laws of West Virginia.

Domestic Insurer

Insurance Commissioner must inspect each insurer every ____ years.

Every 5 years

_____ ______ contract to provide hospital, medical, or dental services between the public and service providers provided under the contract. The corporation is controlled by a board of governors (___% representing health care providers, ___% representing consumers, elderly persons, businesses, and unions).

Health corporations / 20% / 80 %

_______ manipulates through the threat of a negative result - the loss of business or the denial of coverage, for instance.

Intimidation

License of insurance agencies expire _______. The insurer must file the appointment with the Commissioner and pay an annual appointment fee by midnight on ______.

June 30th / May 31st.

_____ _____ corporations operate for the sole purpose of contracting between the public and physicians, dentists and podiatrists for medical or surgical services, and with chiropractors and other health care providers to be furnished to subscribers under terms of their contract with the corporation.

Medical service

______ occurs if a buyer of an insurance policy is given anything of significant value as an inducement to purchase or renew a policy. Any inducement in the sale of insurance that is not specified in the insurance contract itself is a ______.

Rebating / rebate

Insurance Licensing Rules

To apply for a producer license, a person must:submit a completed application, payment of all fees, and completed the required prelicensing course and pass the license examination. The person must not intend to primarily use the license solely for obtaining insurance coverage of himself, family, property, or business. The Commissioner evaluates an applicant to determine if he or she is trustworthy or competent.

Transact insurance means to _____, _____, or _____ insurance.

Transact insurance means to negotiate, sell, or solicit insurance.

______ is knowingly making misleading, incomplete, or fraudulent comparison of policies to induce a person to purchase a policy

Twisting

___________ means a person or insurer engaged in the transaction of insurance without a license in force pursuant to the laws of this state unless exempted by the insurance laws of this state, or any person assisting an unauthorized insurer.

Unauthorized insurer

An insurer formed under the laws of a country other than the United States.

alien insurer

No policy may be delivered in the state unless an outline of coverage is provided. The outline of coverage must detail the benefits and coverages, as well as any limitations and exclusions. The outline must be delivered with the policy for direct response insurance products and at the time of ______ for all other types of insurance products.

application

A _______ is a form of intimidation in which an individual or group refuses to do business with a company or individual, either to drive them out of business or to force them to act in certain way.

boycott

If after notice and a hearing, the Commissioner determines a person or insurer has violated any insurance law, regulation, rule, or order, he may issue a ___________ to that person to discontinue the violation.

cease and desist order

If the Commissioner has reason to believe a person has committed an unfair trade practice, he may issue a _______. If the person disobeys or fails to comply with the order, the Commissioner may assess a penalty of up to $______.

cease and desist order / $10,000

Debtor group life insurance is issued to a _____, who is the policyholder, to insure its debtors who have installment debt or lump-sum payable within _______ of the initial debt.

creditor / 18 months

Unethical producers practice ______ by spreading rumors or falsehoods about the character of competing producers or about the financial condition of another company.

defamation

Any provision limiting or excluding coverage of preexisting conditions must be on the ______ ______ of the policy and in the outline coverage under the title "Preexisting Condition Limitation. "

first page

Agents must determine whether the individual is replacing an existing Medicare supplement insurance policy. The application form contains a notice approved by the Commissioner containing questions to determine whether a replacement transaction exists. The applicant and the agent must sign the form, and the insurer must retain the form for _____ years.

five

An insurer formed under the laws of the United States or of another state of the United States.

foreign insurer

Renewability: Each policy or certificate must contain a renewal, continuation, or nonrenewal provision. The provision must be appropriately displayed on the _____ _____ of the policy.

front page

An ______ ______or ______ is an individual appointed by an insurer to solicit, negotiate, sign or countersign insurance contracts in its behalf. Any person who solicits an application for insurance within the state shall be regarded as the agent of the insurer and not the agent of the insured.

insurance producer or agent

Any written or oral statement that does not accurately describe a policy's benefits, conditions, or coverage is considered a ______.

misrepresentation

The West Virginia Health Insurance Plan was established to provide health insurance to residents of West Virginia, who has been rejected or refused issue of health insurance by at least _____ insurer, and is unable to obtain insurance.

one

If the policy uses the terms "usual and customary," "reasonable and customary," or any other similar words or phrases, the policy must include a definition of the term in the policy and the ______ __ ______.

outline of coverage

HMOs receive premiums on a prepaid _____ ______ basis, excluding copayments.

per capita

Any agent who directly or indirectly effected any insurance contract of an insurer not licensed to transact insurance in the state is ______ _______ as if the insurer of the contract.

personally liable

Accident-only policies must state on the first page of the policy: "This is an accident-only policy, and it does not pay benefits from ______."

sickness

No Medicare supplement policy may exclude or limit benefits for losses incurred more than ____ months from the effective date of coverage because it involves a preexisting condition.

six

The West Virginia Health Insurance Plan is controlled by the board, consisting of the Commissioner or his designated representative, who serves as chair and non-voting member, and ___ members appointed by the ______. At least two board members are individuals reasonably expected to qualify for coverage by the plan, and at least two board members are representatives of insurers, and at least one board member is a health care provider. No more than three members may represent insurers or health care providers. The board selects a plan administrator to manage the plan.

six / Governor

Producers who sell burial insurance or engage solely in telemarketing insurance products by scripted presentation are only required to complete ________ of continuing education every ______.

six hours / two years

Any person or insurer may seek appeal of any action by the Commission in ______. Likewise, the Commissioner may seek a ________ to enforce an order.

state court / court order

If a group life insurance policy is terminated, each individual may convert to an individual policy within _____. ______ ______ is NOT available. Conversion is only eligible for those whose insurance terminates and has been insured for at least ______ under a group policy issued at least ______ prior to the termination date.

term insurance / three years / five years

Advertisements shall be ______and not misleading __ ___or by _______. No person shall make, publish, disseminate, or place before the public an advertisement, which is untrue, deceptive or misleading.

truthful / in fact / implication

All licenses extend for ____ _____ from the date of licensure ending on the last day of ___________________.

two years / the licensee's birth month