Distribution and Claims-Focused InsurTechs: Understanding Licensure and Top 5 Regulatory Issues

Locke Lord LLP

Welcome back to your weekly dose of InsurTech insight. Hopefully in time you’ll come to think of us as a kind of General Assembly for InsurTechs, but instead of learning technological skills, you’ll learn practical information regarding not only regulatory and transactional insurance matters applicable to the InsurTech space, but also issues related to being an entrepreneur (which we will begin to focus on in the second month of this blog). As promised, this week we will take a quick look at determining where your innovation fits within the insurance industry’s ecosystem and the key regulatory issues you will need to navigate.

As a refresher from last week’s post, remember that every insurance company in the industry (regardless of the type of insurance sold) relies on four key areas for its success: distribution, claims, underwriting, and finance. In each of these four areas, there are at least two levels of regulation: licensure requirements and restrictions on your actions. While it may seem at the beginning that obtaining and maintaining licenses is the largest hurdle to clear, it is often the underlying regulatory regimes that are the more arduous because the business of insurance is regulated on the state-level, requiring nuanced attention to the differences and trends under each state’s laws. This week we focus on Distribution and Claims portion of the industry and next week we’ll focus on Underwriting and Finance/ Reinsurance.

I. Distribution
The main goal of Distribution in the insurance industry is the acquisition and retention of customers. Because insurance is a business reliant on the “Law of Large Numbers,” the more data points customers an insurance company has, the more likely that reality will conform to its underwriting models and there will be a larger and more diverse risk pool to absorb losses. As such, without Distribution the industry turns into one large thought exercise (RIP Schrödinger’s cat). Distribution-focused InsurTechs come in many forms. There are those that sell policies for multiple insurance companies (acting as a type of KAYAK for insurance coverages), those that develop killer API, those that develop more pinpoint lead generation, and those that simply focus on working with insurance companies to develop better UI and mobile platforms – because everyone now wants to do things with a click of a button. Unfortunately, our predecessors didn’t have modern technology in mind 50+ years ago when a number of the nation’s insurance laws and regulations were written.

A. Distribution Related Insurance Licensure
Whether you will need a license in the Distribution space really comes down to two key issues: (1) are you “selling, soliciting or negotiating” insurance coverage and (2) do you want to be paid based on a percentage of the successful sales? If the answer to both of those questions is no, you likely will not need an insurance-related license for your Distribution focused activities.

However, if the answer is yes to either of those questions, then you will probably need to be licensed as an insurance agency. Moreover, because insurance is regulated on a 50 state basis (the gift that keeps on giving to us insurance regulatory lawyers), not only will you need a license in your primary place of business, but you will also likely need one in every other state (assuming you want to sell to people and companies from sea to shining sea). But the good news is that within the realm of insurance regulation, insurance agency licensure is relatively straightforward.

In short, licensure as an insurance agency requires that at least one officer or director also be individually licensed, which requires that person submitting an application and passing an exam in the person’s resident state. Once licensed in a resident state, the National Insurance Producer Registry (NIPR) provides for an efficient process to get licensed as “non-resident” producer in all 50 states (and, for the most part, will not require duplicate testing in non-resident states).

It is important to remember that separate insurance licenses are required to sell P&C, A&H and Life. And, if you pride yourself on adventurous and non-standard insurance coverage, you may also need to consider a surplus lines broker license as well, which allows you to sell coverage that standard licensed insurers won’t cover – a topic we will be covering in greater depth in future articles. Finally, if you plan on doing both sales and underwriting (and anticipate providing a significant amount of particular insurance company’s business), you will likely need to comply with managing general agency requirements as well, again something we’ll cover more in the coming weeks.

B. Five Key Regulatory Regimes to Know for Distribution-Focused InsurTechs

  • E-Commerce: While “one-click” optionality and paperless delivery sound great, it’s important to note that insurance laws still require “paper” in many situations. For example, while the vast majority of states allow for the delivery of policies by email, there are still about a dozen that do not. Furthermore, many states still require non-renewal and cancellations to always be delivered by mail. Also, while “wet signatures” are generally no longer required, there are important requirements to follow when obtaining e-signatures. All of these requirements often are a surprise to InsurTechs who assume that the insurance industry operates like the rest of modern day commerce.
  • Anti-Inducement Laws: One of the tougher concepts that InsurTechs often have trouble grasping is that they are generally not allowed to provide potential insureds with benefits for signing up for insurance. In short, the general rule of thumb is you can’t offer a potential customer any benefit that is not included in the four corners of their insurance policy. While there are always exceptions (we are looking at you California and Zenefits), unless it’s something de minimis (think beer koozie) or otherwise included in a filed policy, it probably would be considered an illegal rebate. So, sorry, you can’t give away an iPhone with every life insurance policy sold. And don’t worry, we’ll explain another day about how certain life and health insurers are, in fact, providing Apple Watches to their policyholders.
  • Referral Fee Resitrctions: As we mentioned above, if you plan on accepting payment based on the successful sale of insurance policies, you probably will need an insurance agency license. The reason for this is that a number of states require that if a company is not liensed as an insurance agency, they may only be paid referral fees, and those fees must be paid for each referral and may not be contingent on the referred person actually purchasing insurance. These compensation restrictions are often the main reason many lead-generation focused InsurTechs go through the trouble of obtaining an insurance agency license.
  • Privacy and Data Security Laws: Privacy concerns permeate every facet of our lives, and that includes the world of insurance. Of crucial importance, New York and handful of other states have implemented regulations that place new cybersecurity requirements to ensure businesses protect their customers’ confidential information from cyber-attacks. Furthermore, if you are handling health information, you may be subect to HIPAA and its state counterparts, something that requires special consideration given the potentially serious penalties for related data breaches. You also have the alphabet soup of other federal laws and their state counterparts, including GLBA, FCRA and CAN-SPAM. Taken together, given the severe penalties associated with non-compliance, privacy and data security may be the most important issues facing every InsurTech company handling customer data.
  • Appointments: Not only do you need to be licensed to sell insurance, most states also require you to hold an appointment from the insurance company whose product you are selling. While the appointment process is relatively straight-forward from a regulatory perspective, we raise it here because obtaining appointments from carriers can be difficult and may require partnering with a general agency or similar entity that already has established relationships with carriers.

I. Claims
The area of Claims is where the rubber really hits the road for the industry. The last thing a customer wants is a long drawn out “battle” with their insurance company to get paid after they just suffered a loss (be it an auto accident, unexpected medical bills, or a death in the family). But a quick, efficient, and seamless claims process is also the best way for carriers to engender customer loyalty. The goal for insurance companies and InsurTechs in this space is the balancing of speedy payments and preventing overpayments (both through human error and insurance fraud).

Claims represent a high-potential opportunity for insurers to increase their operational efficiency. Innovative tools such as telematics, the internet of things and drones, allow insurers and claims adjusters access to more data and information in real time, which speeds up the whole claims process from prevention (everything from telemedicene preventing ER visits to automated messages from water boilers when they need repairs before a catastrophic failure), to loss notification (smart phones have made a once tedious process incredibly efficent), to assessment (it’s much easier and safer for drones to see roof damage from a hurricane than having a person climb a rickety 20-foot ladder), to adjustment and payment (using AI to detect insurance fraud in big data).

A. Claims-Related Insurance Licensure
For the most part, the insurance regulators primarily are focused on the assessment, adjustment and payment portions of the Claims process from a licensing standpoint. As such, if you move past developing the technology and licensing it out to insurers to use directly (think SaaS) and actually engage in the process of claims adjusting, you will need to be licensed under the laws of the state you are working in.

Unlike insurance agency licensure, which is relatively the same across the various lines of business, claims adjusting is bifurcated between the P&C side (claims adjuster licenses) and the A&H / Life side (third party administrator and utilization review organizations). On the P&C side, claims adjusting licenses are further broken down between public adjusters (those that represent policyholders) and traditional claims adjusters (who represent the insurance companies). As with insurance agent licenses, there are both individual and corporate licenses that need to be obtained and licensure is required in both resident and non-resident states. Thankfully, NIPR exists for claims adjuster licensing as well, so once you get your resident state license expanding into other states is relatively painless (from a licensure standpoint!). Also, some states will allow for exemptions from various adjuster or third party administrator licenses when agency or other various licenses are held.

On the health side, it’s a whole ’nother ball game. Because claims handling is one of the core components of the definition a “third party administrator,” InsurTechs who are actually adjusting claims in the A&H / Life space likely will need to go through the relatively time-consuming process of obtaining a TPA license in most states. Unfortunately, because TPA licensure also grants underwriting authority, the TPA licensure process is much more involved than a P&C adjuster license. In addition, if you are on the health side of things and addressing the medical necessity, appropriateness, and efficiency of health care services, your start up will also need to be licensed as a utilization review organization in more than a handful of states. As with TPA licensure, obtaining URO licenses is not as “easy” as simply taking an exam and filling out an application. Because of the relatively heavier lift on the licensure side of things, we see more InsurTechs focused on providing the techinical infastructure to insurance carriers and established TPAs and UROs through SaaS and similar arrangments.

B. Five Key Regulatory Regimes to Know for Claims-Focused InsurTechs

  • E-Commerce: Yep. Again. Understanding when and how consumer notices and claims submissions can be submitted online vs. paper is as crucial in Claims as it is in Distribution.
  • Data Security and Privacy: I promise, laziness is not the cause of us reusing these issues. Because nearly every aspect of the Claims process involves obtaining additional information from not only the carrier’s insureds, but also third parties, InsurTechs in the Claims space have to be especially aware of the data flowing through their systems and ensuring that proper protocols are followed to keep the information private and used only for permitted purposes and to prevent data security breaches.
  • Mandatory Disclosures and Timelines: For those InsurTechs involved in the managing the Claims experience, getting a handle on mandatory disclosures and claim payment timelines is often a steep learning curve. Failure to acknowledge, pay, investigate, or deny a claim within the statutorily mandated timeframe can lead to fines, lawsuits, and the revocation of your license. While you may be thinking, “I can write these rules into an app,” it is important to realize that it can become increasingly difficult to meet these deadlines when large scale catastrophes hit, as they increasingly have in the last few years.
  • Consumer Complaints: There are three constants in life: death, memes, and consumer complaints to insurance regulators regarding Claims. These often occur when consumers feel they did not get the benefit of the bargain they thought they made. InsurTechs who are not prepared on how to manage, monitor and efficiently address consumer complaints and the related regulatory inquires are setting themselves up for increased regulatory attention – something no company wants.
  • Compensation Restriction: Adjusters and TPAs cannot be paid more because they reduce the amount a carrier pays out in claims. While at first blush this appears counterintuitive from a business standpoint to many InsurTechs, the public policy goal is to ensure that adjusters and TPAs are not incentivized to simply deny every possible claim in order to receive higher compensation.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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