Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment clarifies standards for
maintaining insurance records in compliance with Missouri law.
PURPOSE: This rule describes the requirements for
record keeping for insurers and related entities doing business in this state.
This regulation was adopted pursuant to the provisions of section
374.045,
RSMo and to implement sections
287.350,
354.190,
354.465,
374.190, 374.210, 375.158, 374.205, 379.343, and 379.475, RSMo and 144.027,
354.149, 354.717, 375.022, 375.150, 375.151, 375.926, 375.932, 375.938,
375.1002, and 375.1009, RSMo.
(1) As used in this rule, the terms and
phrases mean as follows:
(A) "Application,"
any written or electronic application form, any enrollment form, any document
used to add coverage under any existing policy, any 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. "Application" does not include
documents, questionnaires or notes generated in response to a request for a
premium quote which did not result in an application for coverage;
(B) "Business entity," as that term is
defined in section 375.012.1(1), RSMo;
(C) "Claim," as that term is defined in
section
20 CSR
100-1.010(1)(B);
(D) "Examiner," a market conduct examiner
authorized by the director to conduct an examination pursuant to section
374.202.2(4), RSMo;
(E) "Inquiry,"
a specific question, criticism or request made in writing to an insurer by a
market conduct examiner duly appointed by the director;
(F) "Insurer," as that term is defined in
section
375.932 or
375.1002, RSMo;
and
(G) "Policy," as that term is
defined in section
375.932(5),
RSMo.
The term "policy" also includes any evidence of coverage
issued by a health maintenance organization to an enrollee.
(2) Records
Maintainance. Every insurer transacting business in this state shall maintain
its books, records, documents, and other business records in a manner so that
the following practices of the insurer may be readily ascertained during market
conduct examinations: claims handling and payment, complaint handling,
termination, rating, underwriting and marketing. Nothing in this regulation
requires an insurer to create records that never existed; however, the division
may request the creation of such records if it believes doing so will reduce
examination costs.
(3) Records to
be Maintained. An insurer that maintains its records in accordance with the
following standards will be considered in compliance with Missouri law.
(A) A Missouri policy record file for each
Missouri policy issued shall be maintained for the duration of the current
policy term plus two (2) calendar years. Missouri policy records shall be
maintained so as to show clearly the policy period, basis for rating and any
imposition of additional exclusions from or exceptions to coverage. Missouri
policy records need not be segregated from the policy records of other states
so long as they are readily available to Missouri market conduct examiners as
set forth under this rule. Missouri policy records shall include the following:
1. The actual, completed application for each
contract.
A. The application shall bear the
signature of the applicant whenever the insurer intends to retain any right to
contest any warranty, representation or condition contained in the
application.
B. The application
shall bear a clearly legible means by which an examiner can identify any
insurance producer involved in the transaction. The examiners shall be provided
with any information needed to determine the identity of said insurance
producer;
2. Any
declaration pages (the initial page and any subsequent pages), the insurance
contract, any certificates evidencing coverage under a group contract, any
endorsements or riders associated with a policy, and any written or electronic
correspondence to or from the insured pertaining to the coverage. If any of
these records has already been filed with the department, a separate copy of
the record need not be maintained in the individual policy files to which the
record pertains, provided it is clear from the insurer's other records or
systems that the record applies to a particular policy and that any data
contained in the record relating to that policy can be retrieved or
recreated;
3. Any binder with terms
and conditions that differ from the terms and conditions of the policy
subsequently issued; and
4. Any
guidelines, manuals or other information necessary for the reconstruction of
the rating and underwriting of the policy. The maintenance at the site of a
market conduct examination of a single copy of each of the above will be
considered satisfactory. If any such rating or underwriting record is computer
based, the records used to input the information into the computer system shall
also be available to the examiners;
(B) A Missouri claim file shall be maintained
for the calendar year in which the claim is closed plus three (3) years. The
claim file shall be maintained so as to show clearly the inception, handling,
and disposition of each claim. The claim file(s) shall be sufficiently clear
and specific so that pertinent events and dates of these events can be
reconstructed. A Missouri claim file(s) shall include the following:
1. Any notification of claim, proof of loss,
claim form(s), proof of claim payment check/draft, notes, contract, declaration
pages, certificates evidencing coverage under a group contract, endorsements or
riders, work papers, any written communication, and any documented or recorded
telephone communication related to the handling of a claim, including the
investigation, payment and/or denial of the claim, and any claim manual(s) or
other information necessary for reviewing the claim. Where a particular
document pertains to more than one (1) file, insurers may satisfy the
requirements of this paragraph by making available, at the site of a market
conduct examination, a single copy of each document;
2. Documents in a claim file received from an
insured, the insured's insurance producer, a claimant, the department or any
other insurer shall bear the initial date of receipt date-stamped by the
insurer in a legible form in ink or some other permanent manner. Unless the
company provides the examiners with written procedures to the contrary, the
earliest date stamped on a document will be considered the initial date of
receipt;
3. In cases of a total
loss on property claims for a motor vehicle, trailer, boat or outboard motor,
where the insurer utilizes the credit procedure contained in section
144.027,
RSMo, for reimbursement of sales tax, the claim file shall contain a copy of
the certification described in section
144.027,
RSMo, attesting to the amount of the insurance proceeds and any deductible
obligation paid by the claimant regarding the loss; and
4. If an insurer, as its regular business
practice, places the responsibility for handling certain types of claims upon
company personnel other than its claims personnel, the insurer need not
duplicate its files for maintenance by claims personnel. These claims records
must be maintained as part of the records of the insurer's operations and must
be readily available to examiners.
Notwithstanding the definition of "claim" at subsection
20 CSR
100-1.010(1)(B), the time standards
for the retention of records for policy files stated at section 374.205.2(2),
RSMo, apply to claims handled by the company's personnel who typically handle
policy files;
(C)
Records to be maintained relating to the insurer's compliance with Missouri's
licensing requirements shall include the Missouri licensing records of each
insurance producer associated with the insurer. Licensing records shall be
maintained so as to show clearly the dates of the appointment and terminations
of each insurance producer. In accordance with the provisions of section
375.158,
RSMo, insurers must have procedures in place to request, review, and document
current licenses of each insurance producer to whom a commission will be paid
or to validate the producer's licensure status prior to the payment of this
commission. Upon request by the director, insurers shall provide documentation
that such license verification procedures were followed. The date of the
receipt by the insurer of the copy of the license shall be indicated by a
date-stamp placed on the license. Unless the company provides the examiners
with written procedures to the contrary, the earliest date stamped on a
document will be considered the initial date of receipt;
(D) The Missouri complaint records maintained
pursuant to section
375.936(3),
RSMo, shall include the actual written
complaints, the insurer's responses and any materials referenced in an
insurer's response that are not otherwise maintained by the insurer, along with
a complaint log or register that shows clearly the total number of complaints
for a period of not less than the immediately preceding three (3) years, the
classification of each complaint by line of insurance, the nature of each
complaint, the disposition of each complaint, and a reference to the location
of the file to which each complaint corresponds. If the insurer maintains the
file in a computer format, the reference in the complaint log or register for
locating such documentation shall be an identifier such as the policy number or
other code, and an identifier key will be provided to the examiners at the time
of an examination; and
(E) The
insurer shall retain declined underwriting files for a period of three (3)
years from the date of declination. The term "declined underwriting file" means
all written or electronic records concerning a policy for which an application
for insurance coverage has been completed and submitted to the insurer or its
insurance producer but the insurer has made a determination not to issue a
policy or not to add additional coverage when requested. A declined
underwriting file shall include an application, any documentation
substantiating the decision to decline an issuance of a policy, any binder
issued without the insurer issuing a policy, any documentation substantiating
the decision not to add additional coverage when requested, and, if required by
law, any declination notification. Notes regarding requests for quotations
which do not result in a completed application for coverage need not be
maintained for purposes of this regulation.
(4) Form of Record.
(A) Any record to be maintained by an insurer
pursuant to Missouri law, may be in the form of paper; photograph; computer;
magnetic, mechanical, or electronic medium; or any process which accurately
forms a durable reproduction of the record, so long as the record is capable of
duplication to a hard copy that is as legible as the original document.
Documents necessitating the signature(s) of the insured and/or insurer's
insurance producer, shall be maintained in any format as listed above provided
evidence of the signature(s) is preserved in that format.
(B) Once a record has been finalized, either
for internal or external transmission or for file documentation purposes, or
once an electronic record or database is finalized for permanent retention
purposes, it shall be maintained in a computer-based format that is archival in
nature, so as to preclude any alteration of the record after the initial
transfer to archival format. All records shall be maintained according to
written procedures developed and adhered to by the insurer. The written
procedures shall be made available upon examiner request.
(C) Photographs, microfilms, or other
image-processing reproductions of records are deemed the equivalent of the
originals and may be certified as the same in actions or proceedings before the
department unless inconsistent with
20 CSR
800-1.100.
(5) Location of Files. All records to be
maintained by an insurer pursuant to Missouri law shall be kept in a location
which will allow the records to be produced for examination within the time
period set out under section (6) of this rule. When, under normal
circumstances, someone other than the insurer maintains a record or type of
record, the other person's or entity's responsibility to maintain the records
shall be set forth in a written agreement, with a copy maintained by the
insurer and made available to the examiners for purposes of
examination.
(6) Time Limits to
Provide Records and to Respond to Examiners.
(A) Pursuant to section 374.205.2(2), RSMo,
an insurer shall provide any record requested by any examiner within ten (10)
calendar days. When the requested record is not or cannot be produced by the
insurer within ten (10) calendar days, this nonproduction is deemed a violation
of section 374.205.2(2), RSMo, and this rule, unless the insurer can
demonstrate to the satisfaction of the director that the requested record
cannot reasonably be provided within ten (10) calendar days of the
request.
(B) As a means to
facilitate the examination and to aid in the examination in accordance with
section 374.205.2(2), RSMo, an insurer shall provide a written response to any
inquiry submitted by any examiner within ten (10) calendar days. When the
requested information is not provided by the insurer within ten (10) calendar
days, a violation is deemed to have occurred, unless the insurer can
demonstrate to the satisfaction of the director that the requested response
cannot reasonably be provided within ten (10) calendar days of the
inquiry.
(7) Examination
Work Papers. Records provided during a market conduct examination will be
returned to the insurer following the examination, unless such records relate
to an inquiry made by a department examiner. Records related to an inquiry
become a part of the work papers of the examination. Section
374.205,
RSMo, and regulation 20 CSR 10-2.400 govern the
public access to the work papers of the examination.
*Original authority: 374.045, RSMo 1967, amended 1993,
1995, 2008 and 375.948, RSMo 1959, amended 1978,
1991.
