Wolters Kluwer analysis reveals timely and accurate claims processing as top compliance challenge for U.S. insurers
Annual review of Top 10 market conduct issues provides vital checklist for insurers
Now in its 17th year, the Top 10 market conduct actions review continues to assist insurers by demonstrating not only the continuity of challenges, but also providing a compliance checklist of operational areas within their own companies that may warrant additional audits to check for adherence to regulatory requirements.
“While technology has helped to streamline and automate some processes, our annual Top 10 market conduct action findings continue to show the ongoing challenges that insurers face in managing their regulatory requirements,” said
The following are listings of the top compliance issues determined in market conduct actions across the
Top 10 Market Conduct Criticisms for Property and Casualty Insurers
- Failure to acknowledge, pay, investigate or deny claims within specified timeframes
- Failure to issue correct payments and/or compliant denial notices
- Using unapproved/unfiled rates and rules or misapplying rating factors
- Failure to process total loss claims properly
- Failure to cancel, non-renew, or decline policies in accordance with requirements
- Failure to adhere to producer appointment, termination, records, reporting and/or licensing requirements
- Failure to provide required compliant notices and disclosures in claims processing
- Improper/incomplete documentation of claim files
- Improper/incomplete documentation of underwriting files
- Failure to provide required compliant notices and disclosures in underwriting processes
Top 10 Market Conduct Criticisms for Life and Health Insurers
- Failure to adhere to required claims utilization review, grievance and appeal processes, including timeframes and disclosures
- Failure to pay claims properly in accordance with policy provisions and comply with claim denial requirements
- Failure to acknowledge, pay, investigate, or deny claims within specified timeframes
- Use of unfiled/unapproved or noncompliant forms; unfiled/unapproved rates
- Failure to provide required and compliant claims, EOBs, underwriting and policyholder disclosures and notices
- Failure to use licensed and/or appointed producers, provide proper notification of producer appointments or terminations and maintain appropriate documentation
- Failure to adhere to suitability requirements
- Failure to adhere to replacement requirements
- Failure to adhere to advertising requirements
- Failure to maintain adequate/complete claims, underwriting and complaint documentation
While these Top 10 lists provide insight into insurers’ ongoing compliance risk challenges, other findings regularly surface as well. Routine determinations by examiners include the failure to consistently identify the legal name of the insurer, as well as failures to adhere to certain state-specific mandates that range from the annual claims training requirement in
The market conduct examination process for insurance companies is complex, time-consuming and costly. To learn more, access Wolters Kluwer’s
Wolters Kluwer’s GRC division provides an array of expert solutions to help financial institutions manage regulatory and risk obligations. The other regulatory compliance business is Wolters Kluwer Finance, Risk & Regulatory Reporting (FRR), and its legal solutions business are
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 help 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.
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Corporate Communications Manager, Banking & Regulatory Compliance
Governance, Risk & Compliance Division
Wolters Kluwer
Tel: +1 612-852-7966
David.feider@wolterskluwer.com
On Twitter: @davidafeider
Source: Wolters Kluwer