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  • Wolters Kluwer Analysis Names Timely Claims Processing as Top Compliance Challenge for Insurers

    Oct. 29, 2018

    Firm’s annual review of Top 10 market conduct issues provides vital checklist for insurers

    Untimely claims handling and failure to provide required compliant claims, underwriting, and policyholder service disclosures are the U.S. insurance industry’s top compliance shortcomings. That’s according to a comprehensive review by Wolters Kluwer of U.S. insurers’ market conduct actions published by state insurance regulators during 2017 along with data compiled by the company in its most recent annual look at U.S. property and casualty, life, and health insurers’ market conduct actions.

    Now in its 14th year, the review serves as a compliance checklist for insurers, providing them a good sense of the business areas that were not only examined by regulators, but also proved to be most challenging for the industry in terms of compliance.

    “Effectively and sustainably embedding regulatory requirements into claims, underwriting and distribution processes continues to pose challenges for insurers,” said Kathy Donovan, Senior Compliance Counsel for Wolters Kluwer’s Insurance Compliance business. “As routine as many of these compliance challenges may appear, these findings underscore the need for a sound compliance program management system, where regulatory requirements and changes—along with compliance risks and controls—are consistently integrated into an insurer’s exam management program in ways that empower it to strengthen its enterprise controls and audit practices.”

    Following is a summary of the top issues identified regarding examiners’ criticisms of insurance departments across the U.S., primarily impacting insurers’ claims and underwriting processes.

    2017 Top 10 Market Conduct Actions for Property and Casualty Insurers

    1. Failure to acknowledge, pay, investigate or deny claims within specified timeframes
    2. Failure to cancel, non-renew, renew policies in accordance with requirements
    3. Failure to issue correct payments and/or compliant denial notices
    4. Failure to provide required compliant disclosures in claims processing
    5. Using unapproved/unfiled rates and rules, or misapplying rating factors
    6. Failure to process total loss claims properly
    7. Failure to adhere to producer appointment, termination, records and/or licensing requirements
    8. Improper/incomplete documentation of underwriting files
    9. Failure to provide required compliant disclosures in underwriting processes
    10. Improper/incomplete documentation of claim files

    2017 Top 10 Market Conduct Actions for Life and Health Insurers

    1. Failure to acknowledge, pay, investigate, or deny claims within specified time frames
    2. Failure to adhere to required claims grievance and appeal processes, including timeframes and disclosures
    3. Noncompliant claim denial notices
    4. Failure to provide required and compliant claims, underwriting, and policyholder disclosures
    5. Failure to pay claims properly in accordance with policy provisions and requirements
    6. Failure to use licensed and/or appointed producers, provide proper notification of producer appointments or terminations, and maintain appropriate documentation  
    7. Use of unfiled/unapproved or noncompliant forms
    8. Failure to adhere to replacement requirements
    9. Failure to issue compliant Explanation Of Benefits notices
    10. Failure to respond to regulatory requests for information                        

    The above lists of top market conduct actions taken against U.S. insurers are developed by Wolters Kluwer using public data published during 2017.

    To access Wolters Kluwer’s 2018 webinar focused on property and casualty market conduct actions, listen here; for the webinar on life and health market conduct actions, listen here. Learn more about Wolters Kluwer’s insurance compliance expertise and solutions. 

    About Wolters Kluwer Governance, Risk & Compliance

    Governance, Risk & Compliance (GRC) is a division of Wolters Kluwer, which provides legal and banking professionals with solutions to ensure compliance with ever-changing regulatory and legal obligations, manage risk, increase efficiency, and produce better business outcomes. GRC offers a portfolio of technology-enabled expert services and solutions focused on legal entity compliance, legal operations management, banking product compliance, and banking regulatory compliance.

    Wolters Kluwer N.V. (AEX: WKL) is a global leader in information services and solutions for professionals in the health, tax and accounting, risk and compliance, finance and legal sectors. Wolters Kluwer reported 2017 annual revenues of €4.4 billion. The company, headquartered in Alphen aan den Rijn, the Netherlands, serves customers in over 180 countries, maintains operations in over 40 countries and employs 19,000 people worldwide.


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