As used in this article:
(a) “Benefits” mean money payments, goods, services, or other thing of value paid in response to a claim filed with an insurer based upon a policy of insurance.
(b) “Business of insurance” means the writing of insurance, including the writing of workers’ compensation insurance under the provisions of §23-1-1et seq.of this code, self-insurance by an employer or employer group for workers’ compensation risk including the risk of catastrophic injuries under the provisions of §23-1-1et seq.of this code, or the reinsuring of risks by an insurer, including acts necessary or incidental to writing insurance or reinsuring risks and the activities of persons who act as or are officers, directors, agents, or employees of insurers, or who are other persons authorized to act on their behalf.
(c) “Claim” means an application or request for payment or benefits provided under the terms of a policy of insurance.
(d) “Commissioner” means the Insurance Commissioner of West Virginia or his or her designee.
(e) “Fraudulent insurance act” means an act or omission committed by a person who knowingly and with intent to defraud misrepresents or conceals any material information concerning one or more of the following:
(1) Presenting, causing to be presented, or preparing with knowledge or belief that it will be presented to or by an insurer, a reinsurer, broker, or its agent, false information as part of, in support of, or concerning a fact material to one or more of the following:
(A) An application for the issuance or renewal of an insurance policy or reinsurance contract;
(B) The rating of an insurance policy or reinsurance contract;
(C) A claim for payment or benefit pursuant to an insurance policy or reinsurance contract;
(D) Premiums paid on an insurance policy or reinsurance contract;
(E) Payments made in accordance with the terms of an insurance policy or reinsurance contract;
(F) A document filed with the commissioner or the chief insurance regulatory official of another jurisdiction;
(G) The financial condition of an insurer or reinsurer;
(H) The formation, acquisition, merger, reconsolidation, dissolution, or withdrawal from one or more lines of insurance or reinsurance in all or part of this state by an insurer or reinsurer;
(I) The issuance of written evidence of insurance; or
(J) The reinstatement of an insurance policy.
(2) Solicitation or acceptance of new or renewal insurance risks on behalf of an insurer, reinsurer, or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction;
(3) Removal, concealment, alteration, or destruction of the assets or records of an insurer, reinsurer, or other person engaged in the business of insurance;
(4) Willful embezzlement, abstracting, purloining, or conversion of moneys, funds, premiums, credits, or other property of an insurer, reinsurer, or person engaged in the business of insurance;
(5) Transaction of the business of insurance in violation of laws requiring a license, certificate of authority, or other legal authority for the transaction of the business of insurance; or
(6) Attempt to commit, aiding, or abetting in the commission of, or conspiracy to commit the acts or omissions specified in this subdivision.
(f) “Health care provider” means a person, partnership, corporation, facility, or institution licensed by, or certified in, this state or another state, to provide health care or professional health care services, including, but not limited to, a physician, osteopathic physician, hospital, dentist, registered or licensed practical nurse, optometrist, pharmacist, podiatrist, chiropractor, physical therapist, or psychologist.
(g) “Insurance” means a contract or arrangement in which a person undertakes to:
(1) Pay or indemnify another person as to loss from certain contingencies called “risks”, including through reinsurance;
(2) Pay or grant a specified amount or determinable benefit to another person in connection with ascertainable risk contingencies;
(3) Pay an annuity to another person;
(4) Act as surety; or
(5) Self-insurance for workers’ compensation risk, including the risk of catastrophic injuries pursuant to the provisions of §23-1-1et seq.of this code.
(h) “Insurer” means a person entering into arrangements or contracts of insurance or reinsurance. Insurer includes, but is not limited to, any domestic or foreign stock company, mutual company, mutual protective association, farmers’ mutual fire companies, fraternal benefit society, reciprocal or interinsurance exchange, nonprofit medical care corporation, nonprofit health care corporation, nonprofit hospital service association, nonprofit dental care corporation, health maintenance organization, captive insurance company, risk retention group, or other insurer, regardless of the type of coverage written, including the writing of workers’ compensation insurance or self insurance under the provisions of this code, benefits provided, or guarantees made by each. A person is an insurer regardless of whether the person is acting in violation of laws requiring a certificate of authority or regardless of whether the person denies being an insurer.
(i) “Person” means an individual, a corporation, a limited liability company, a partnership, an association, a joint stock company, a trust, trustees, an unincorporated organization, or any similar business entity, or any combination of the foregoing. “Person” also includes hospital service corporations, medical service corporations, and dental service corporations as defined in §33-24-1et seq.of this code, health care corporations as defined in, §33-25-1et seq.of this code, or a health maintenance organization organized pursuant to §33-25A-1et seq.of this code.
(j) “Policy” means an individual or group policy, group certificate, contract or arrangement of insurance or reinsurance, coverage by a self-insured employer or employer group for its workers’ compensation risk including its risk of catastrophic injuries or reinsurance, affecting the rights of a resident of this state or bearing a reasonable relation to this state, regardless of whether delivered or issued for delivery in this state.
(k) “Reinsurance” means a contract, binder of coverage (including placement slip) or arrangement under which an insurer procures insurance for itself in another insurer as to all or part of an insurance risk of the originating insurer.
(l) “Statement” means any written or oral representation made to any person, insurer or authorized agency. A statement includes, but is not limited to, any oral report or representation; any insurance application, policy, notice or statement; any proof of loss, bill of lading, receipt for payment, invoice, account, estimate of property damages, or other evidence of loss, injury or expense; any bill for services, diagnosis, prescription, hospital or doctor record, X-ray, test result or other evidence of treatment, services or expense; and any application, report, actuarial study, rate request or other document submitted or required to be submitted to any authorized agency. A statement also includes any written or oral representation recorded by electronic or other media.
(m) “Unit” means the insurance fraud unit established pursuant to the provisions of this article acting collectively or by its duly authorized representatives.