W. Va. Code R. § 114-25-3

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 114-25-3 - License Requirements

3.1. No person shall in West Virginia act as or hold himself to be an adjuster unless licensed by the Commissioner.

3.2. Notwithstanding any other provisions of this rule, a company adjuster's license or independent adjuster's license shall not be required of, the following:

3.2.a. An attorney-at-law admitted to practice in this state, when acting in their professional capacity as an attorney;

3.2.b. A person employed solely to obtain facts surrounding a claim or to furnish technical assistance to a licensed company or independent adjuster;

3.2.c. An individual who is employed to investigate suspected fraudulent insurance claims but who does not adjust losses, investigate or determine coverage, or determine claims payments;

3.2.d. A person who solely performs executive, administrative, managerial or clerical duties or any combination thereof and who does not investigate, negotiate or settle claims with policyholders, claimants or their legal representative;

3.2.e. A licensed health care provider or its employee who provides managed care services so long as the services do not include the determination of compensability;

3.2.f. A managed care organization or any of its employees or an employee of any organization providing managed care services so long as the services do not include the determination of compensability;

3.2.g. A person who settles only reinsurance or subrogation claims;

3.2.h. An officer, director or manager of an authorized insurer or surplus lines insurer or a risk retention group or of a related holding company or an affiliated insurer, in the state, whether an individual or a business entity, or an attorney-in-fact of a reciprocal insurer;

3.2.i. A U.S. Manager of the United States branch of an alien insurer;

3.2.j. A person who investigates, negotiates or settles life, accident and sickness, annuity or disability insurance claims;

3.2.k. An individual employee, under a self-insured arrangement, who adjusts claims on behalf of his or her employer;

3.2.l. A licensed insurance producer, attorney-in-fact of a reciprocal insurer or managing general agent of the insurer to whom claim authority has been granted by the insurer;

3.2.m. A person who adjusts claims for licensed farmers' mutual fire insurance companies;

3.2.n. A business entity licensed under the authority of W.Va. Code § 33-46-1, et seq. of this code;

3.2.o. An individual who collects claims information from, or furnishes claim information to, insureds or claimants and who conducts data entry, including data into an automated claims adjudication system, so long as the individual is under the supervision of a licensed adjuster or producer and, further, that the licensed adjuster or licensed producer supervises no more than 25 unlicensed persons; or

3.2.p. A company adjuster employed by an insurer outside of the state of West Virginia who adjusts claims solely by telephone, fax, United States mail, and electronic mail, and who does not physically enter this state in the course of adjusting such claims.

3.3. Notwithstanding any other provisions of this rule, a public adjuster's license shall not be required of the following:

3.3.a. An attorney-at-law admitted to practice in this state, when acting in their professional capacity as an attorney;

3.3.b. A person who negotiates or settles claims arising under a life of health insurance policy or annuity contract;

3.3.c. A person employed only for the purpose of obtaining facts surrounding a loss or furnishing technical assistance to a licensed public adjuster;

3.3.d. A licensed health care provider, or employee of a licensed health care provider, who prepares or files a health claim form on behalf of a patients; or

3.3.e. A person who settles subrogation claims between insurers.

3.4. Claims arising out of a particular loss of unique or unusual character may be adjusted by a non-licensed adjuster upon registration with the Commissioner as long as the work of the non-licensed person is supervised by either an adjuster licensed in this state or an insurance company authorized to do business in this state; Provided, That the authority to work granted as provided herein to unlicensed persons is limited to three losses within any twelve month period.

3.5. A company adjuster who is exempt from licensing requirements pursuant to section 3.2.p and W.Va. Code § 33-12B-3(a)(15) is subject to the jurisdiction of, and regulation by, the Commissioner in regard to his or her adjustment of West Virginia claims. The Commissioner may require such exempt adjusters to complete continuing education courses, not to exceed 24 hours per biennium, to address any deficiencies with respect to his or her claims handling practices.

W. Va. Code R. § 114-25-3