W. Va. Code R. § 114-15-2

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-15-2 - Definitions

As used in this legislative rule:

2.1. "Accredited examiner" or "examiner" means a person who is an employee of the insurance commissioner whose principle duty is to conduct, supervise, or provide technical support for financial or market conduct examinations, including but not limited to the following division of personnel job classifications: insurance company examiner, or insurance company examiner supervisor, market conduct examiner, market conduct examiner supervisor, or computer audit specialist, pursuant to the classification plan of the West Virginia division of personnel or such other equivalent classification plan as the state of West Virginia may adopt.

2.2. "Additional examination assessment fee" means any additional or increased examination assessment fee levied by order of the commissioner in excess of the annual examination assessment fee as allowed by the provisions of W. Va. Code § 33-2-9.

2.3. "Application and accompanying records" means any written or electronic application form, any enrollment form, any document or record thereof, used to add coverage under any existing policy, questionnaire, telephone interview form, paramedical interview form or any other document used to question or underwrite an applicant for any policy issued by an insurer or for any declination of coverage by an insurer.

2.4. "Claim file and accompanying records" means the file maintained so as to show clearly the inception, handling and disposition of each claim. The claim file shall be sufficiently clear and specific so that pertinent events and dates of these events can be reconstructed.

2.5. "Commissioner" means the insurance commissioner of the state of West Virginia.

2.6. "Complaint" means a written communication primarily expressing a grievance.

2.7. "Declination" or "declined underwriting file" means all written or electronic records concerning coverage for which an application has been completed and submitted to the insurer or its producer but the insurer has made a determination not to issue a policy or not to add additional coverage when requested.

2.8. "Examination assessment fee" means the annual fee due on or before the first day of July of every year, as specified in W. Va. Code § 33-2-9.

2.9. "Governor's travel rules" means those rules promulgated by the governor pursuant to the authority granted by W. Va. Code § 12-3-11.

2.10. "Grievance" for health insurance purposes, means a written complaint submitted by or on behalf of a covered person regarding the:

a. Availability, delivery or quality of health services, including a complaint regarding an adverse determination made pursuant to utilization review;

b. Claims payment, handling or reimbursement for health care services; or

c. Matters pertaining to the contractual relationship between a covered person and a health carrier.

2.11. "Incidental expense" means any reasonable travel-related expense other than charges for lodging, meals or mileage, including but not limited to tolls, parking, gratuities or public transportation.

2.12. "Inquiry" means a specific question, criticism or request made in writing to an insurer by an examiner.

2.13. "Insurer" as used in this rule, means any entity covered by the scope of this rule pursuant to subdivision c, subsection 1.1 of this rule, unless otherwise specified herein.

2.14. "Lodging" means a temporary place of abode, such as a hotel, maintained by the examiner for the convenience of being closer to the examination site, and at which the examiner has no intention of establishing residence.

2.15. "On-site" or "site" means at or conveniently proximate to the business location of the entity being examined, as listed on the examiner's semi-monthly days worked report, but does not include the offices of the insurance commissioner when work related to an examination is performed there.

2.16. "Other employee" means any individual who is an employee of the offices of the insurance commissioner of West Virginia, excluding the commissioner's accredited examiners.

2.17. "Other individual or entity" means any individual, corporation, partnership or other business entity that is not an employee of the offices of the insurance commissioner, to include but not be limited to independent certified public accountants, independent actuaries, qualified insurance examiners, reinsurance examiners, investment or information systems specialists or other individuals, corporations, partnerships or other business entities with particular skills or areas of expertise, considered competent by the commissioner to conduct or participate in any examination, analysis or review as allowed by W. Va. Code § 33-2-9 or this rule.

2.18. "Related entity" means a person authorized to act on behalf of the insurer in connection with the business of insurance.

2.19. "Residence" means a permanent or semi-permanent place of abode, maintained solely for the convenience of the examiner and not in connection with an on-site examination assignment, including the examiner's domicile and any temporary residence established by the examiner.

W. Va. Code R. § 114-15-2