casual office workers
ComplianceOctober 02, 2020

Wolters Kluwer analysis reveals timely claims processing is top compliance challenge for US insurers

Annual review of Top 10 market conduct issues provides vital checklist for insurers

The U.S. insurance industry’s top compliance shortcomings relate to claims handling noncompliance, including timeliness, required disclosures, benefit payments and grievance processes, as well as underwriting, rating and insurance producer issues. That’s according to a comprehensive review by Wolters Kluwer’s Compliance Solutions business of U.S. insurers’ market conduct actions. The annual review uses public data from 2019 and looks at U.S. property and casualty, life, and health insurers’ market conduct actions, including exams and other enforcement actions.

Now in its sixteenth year, the Top 10 market conduct actions review continues to assist insurers by 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 results continue to show the ongoing challenges insurers face in managing their regulatory requirements,” said Steven Meirink, Executive Vice President and General Manager for the Compliance Solutions business. “However, a robust compliance program management approach that includes a strong risks and controls framework can be key to helping improve insurers’ success rate in market conduct compliance.”

The following are listings of the top compliance issues determined in market conduct actions across the U.S. by state insurance regulators. These are primarily found in insurers’ claims and underwriting processes.

2019 Top 10 Market Conduct Criticisms for Property and Casualty Insurers

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

2019 Top 10 Market Conduct Criticisms for Life and Health Insurers

  1. Failure to acknowledge, pay, investigate, or deny claims within specified time frames
  2. Failure to pay claims properly in accordance with policy provisions and requirements/noncompliant claim denials
  3. Failure to adhere to replacement requirements
  4. Failure to adhere to required claims utilization review, grievance and appeal processes, including timeframes and disclosures
  5. Use of unfiled/unapproved or noncompliant forms
  6. Failure to use licensed and/or appointed producers, provide proper notification of producer appointments or terminations and maintain appropriate documentation
  7. Failure to provide required and compliant claims, underwriting and policyholder disclosures and notices
  8. Failure to issue compliant EOBs
  9. Failure to maintain adequate/complete claims and underwriting documentation
  10. Failure to adhere to advertising requirements

To learn more, access Wolters Kluwer’s September 2020 webinar focused on Top 10 property and casualty market conduct actions or the webinar on Top 10 life and health market conduct actions. The market conduct examination process for insurance companies is complex, time-consuming and costly. Wolters Kluwer’s Exam & Management solutions help insurance companies in managing these compliance challenges.

Governance, Risk & Compliance 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.
About Wolters Kluwer

Wolters Kluwer (WKL) is a global leader in professional information, software solutions, and services for the health, tax & accounting, governance, risk & compliance, and legal & regulatory sectors. We help our customers make critical decisions every day by providing expert solutions that combine deep domain knowledge with specialized technology and services.