NYSDFS Examination Report - Health Insurance - A-H: Oscar Insurance Corporation - Combined

REPORT ON EXAMINATION

OF

OSCAR INSURANCE CORPORATION

AS OF

DECEMBER 31, 2015

DATE OF REPORT JANUARY 31, 2018

EXAMINER FROILAN L. ESTEBAL

TABLE OF CONTENTS

ITEM NO. PAGE NO.

1. Scope of the examination 2

2. Description of the Company 5

A

.

Corporate governance 5

B. Enterprise risk mangement 8

C. Internal audit 10

D. Territory and plan of operation 10

E. Reinsurance 11

F. Holding company system 12

G. Significant operating ratios 14

H. Allocation of expenses 14

I. Medical loss ratio reporting 16

3. Financial statements 21

A

.

Balance sheet 22

B

.

Statement of revenue and expenses and capital and surplus 23

4. Claims unpaid and unpaid claim adjustment expenses 26

5. Market conduct activities 27

A. Explanation of benefits statements 27

B. Utilization review 28

C. Utilization review appeal 31

D. Prompt payment of claims 33

6. Summary of comments and recomendations 35

2

Andrew M. Cuomo Maria T. Vullo

Governor Superintendent

January 31, 2018

Honorable Maria T. Vullo

Superintendent of Financial Services

Albany, New York 12257

Pursuant to the provisions of the New York Insurance Law, and acting in accordance with

the instructions contained in Appointment Number 31418, dated January 29, 2016, attached hereto,

I have made an examination into the condition and affairs of Oscar Insurance Corporation, an

accident and health insurer licensed pursuant to the provisions of Article 42 of the New York

Insurance Law, as of December 31, 2015, and submit the following report thereon.

The examination was conducted at the administrative office of Oscar Insurance

Corporation, located at 295 Lafayette Street, New York, NY.

Wherever the designations the “Company” or “Oscar NY” appear herein, without

qualification, they should be understood to indicate Oscar Insurance Corporation.

Wherever the designation, the “Parent” appears herein, without qualification, it should be

understood to indicate Mulberry Health, Inc.

Wherever the designation, the “Department” appears herein, without qualification, it

should be understood to indicate the New York State Department of Financial Services.

ONE STATE STREET, NEW YORK, N Y 10004 | WWW.DFS.NY.GOV

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1. SCOPE OF THE EXAMINATION

This is the first examination of the Company. This examination was a combined (financial

and market conduct) examination and covered the period from the Company’s inception, June 12,

2013 through December 31, 2015. The financial component of the examination was conducted as

a financial examination, as defined in the National Association of Insurance Commissioners

(“NAIC”) Financial Condition Examiners Handbook, 2016 Edition (the “Handbook”). The

examination was conducted observing the guidelines and procedures in the Handbook. Where

deemed appropriate by the examiner, transactions occurring subsequent to December 31, 2015,

were also reviewed.

The examination was conducted on a risk-focused basis in accordance with the provisions

of the Handbook, which provides guidance for the establishment of an examination plan based on

the examiner’s assessment of risk in the Company’s operations, and utilizes that evaluation in

formulating the nature and extent of the examination. The examiner planned and performed the

examination to evaluate the Company’s current financial condition, as well as to identify

prospective risks that may threaten the future solvency of the Company.

The examiner identified key processes, assessed the risks within those processes and

assessed the internal control systems and procedures used to mitigate those risks. The examination

also included an assessment of the principles used and significant estimates made by management,

an evaluation of the overall financial statement presentation, and determined management’s

compliance with the Department’s statutes and guidelines, Statutory Accounting Principles, as

adopted by the Department, and NAIC Annual Statement instructions.

3

Information concerning the Company’s organizational structure, business approach and

control environment was utilized to develop the examination approach. The examination

evaluated the Company’s risks and management activities in accordance with the NAIC’s nine

branded risk categories. These categories are as follows:

 Pricing/Underwriting

 Reserving

 Operational

 Strategic

 Credit

 Market

 Liquidity

 Legal

 Reputational

The examination also evaluated the Company’s critical risk categories in accordance with

the NAIC’s ten critical risk categories. These categories are as follows:

 Valuation/Impairment of Complex or Subjectively Valued Invested Assets

 Liquidity Considerations

 Appropriateness of Investment Portfolio and Strategy

 Appropriateness/Adequacy of Reinsurance Program

 Reinsurance Reporting and Collectability

 Underwriting and Pricing Strategy/Quality

 Reserve Data

 Reserve Adequacy

 Related Party/Holding Company Considerations

 Capital Management

The Company was audited in 2015 by the accounting firm of Deloitte & Touche LLP

(“D&T”). The Company received an unqualified opinion for the period. Certain audit workpapers

of D&T were reviewed and relied upon in conjunction with this examination.

4

Audits for calendar years 2013 and 2014 were performed by BDO USA and such audits

were also found to represent fairly the financial position of the Company at those respective audit

dates.

This examination was conducted as a coordinated examination, as such term is defined in

the Handbook (an examination of one insurer or a group of insurers performed by examiners from

more than one state whereby the participating states share resources and allocate work among the

examiners), of the insurance subsidiaries of Mulberry Health, Inc. The examination was led by

the State of New York with participation from the Texas Department of Insurance. Since the Lead

and Participating states, as such terms are defined in the Handbook, are accredited by the NAIC,

the states deemed it appropriate to rely on each other’s work. The examination team, representing

the Lead and Participating states, identified and assessed the risks for key functional activities

across all of Mulberry Health, Inc.’s insurance subsidiaries. The examination team also assessed

the relevant prospective risks as they relate to the various insurance entities.

During this examination, a review was made of the Company’s IT systems and operations

on a risk-focused basis, in accordance with the provisions of the Handbook.

This report on examination is confined to financial statements and comments on those

matters which involve departure from laws, regulations or rules, or which require explanation or

description.

5

2. DESCRIPTION OF THE COMPANY

The Company is a wholly-owned subsidiary of Mulberry Health Inc., a Delaware

Corporation. Oscar Insurance Corporation filed a Uniform Certificate of Authority Application

for licensure as a New York Insurance Law Article 42 accident and health insurer with the New

York State Department of Financial Services on December 12, 2012. Subsequently, on January

31, 2013, Oscar NY was incorporated, pursuant to the Company’s submission of a Declaration of

Intention and Charter (“Charter”) to the Department. Such Charter was approved by the

Department, pursuant to Section 1201 of the New York Insurance Law, and placed on file the same

date. On February 19, 2013, the Company issued 20,000,000 shares of $.01 par value per share

capital stock for a price of $.015 per share to it’s Parent, resulting in an aggregate purchase price

of $300,000. These funds were infused to establish a statutory investment account in the name of

the Superintendent of Financial Services. The Company was licensed by the Department on July

12, 2013. A report on organization was conducted and filed on July 5, 2013.

A. Corporate Governance

The Company’s by-laws stipulate that the number of directors, which shall constitute the

whole board of directors, shall be fixed from time to time by resolution of the Shareholders,

consistent with the provisions of the Charter. Oscar NY’s Charter states that the corporation shall

consist of not less than seven, nor more than ten members. As of the date of this examination, the

seven members of the board of directors were as follows:

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Name and Residence

Joel Cutler

Boston, MA

David Henderson

Loudonville, NY

Joshua Kushner

New York, NY

Christopher Paik

New York, NY

Mario Schlosser

New York, NY

Jared Weinstein

New York, NY

Kareen Zaki

New York, NY

Principal Business Affiliation

General Catalyst,

Managing Director

Oscar Insurance Corporation,

President of Insurance

Oscar Insurance Corporation,

Chairman

Thrive Capital Management, LLC,

Investor

Oscar Insurance Corporation,

Chief Executive Officer and Treasurer

Thrive Capital Management, LLC,

Chief of Operations

Thrive Capital Management, LLC,

Investor

The Board met at least five times during 2014 and 2015, including quarterly meetings, in

compliance with Article III, Section 5 of the Company’s by-laws, which specifies that the Board

is to meet at least once annually.

A review of the attendance records of the Board of Directors’ meetings held during the

examination period revealed that meetings were generally well attended, with all members

attending at least one half of the meetings they were eligible to attend.

7

The principal officers of the Company as of December 31, 2015, were as follows:

Name Title

Mario Schlosser Chief Executive Officer and Treasurer

Joshua Kushner Chairman

Steven Kessler Chief Financial Officer

David Henderson President of Insurance

Kevin Campbell Chief Operating Officer

Shilpa Patel Secretary

Dr. Aran Ron Chief Medical Officer

Changes to the board of directors

Effective November 4, 2015, Kevin Campbell was elected as a member of the board of

directors. Effective March 7, 2016, and subsequent to the examination date, Joshua Kushner and

David Henderson resigned as members of the Company’s board of directors. Effective the same

date, Steven Kessler, Joel Klein, Brian West, and Alan Warren were elected as members of the

board of directors.

The 2016 NAIC Financial Conditions Examiners Handbook (pg. 200) states in part:

“…it is important that the board contain at least a critical mass of outside directors. The

number should suit the entity’s circumstances, but more than one outside director would

normally be needed for a board to have the requisite balance.”

The changes in composition of the board of directors in 2016 indicate that six of the

succeeding board members, or 86%, were also officers of the Company, which includes the Chief

Executive Officer. Five of the directors/officers report directly to the CEO. As listed on the 2016

Jurat Page, there is only one director (Kareem Zaki) who is not listed as an officer of the Company.

Mr. Zaki, however, is an investor and member of Thrive Capital, who is therefore also not

8

independent of the Company. This significant change in membership, subsequent to the

examination, eliminated all but one of the external members of the board and replaced them with

officers of the Company.

It is recommended, as a best practice per the NAIC Examiner’s Handbook, that the

Company include a fair representation of independent members on its board of directors.

B. Enterprise Risk Management

Section 82.2 (Enterprise risk management) of Insurance Regulation 203(11 NYCRR 82)

states in part:

“(a) Pursuant to Insurance Law sections 1503(b), 1604(b), and 1717(b), an entity shall

adopt a formal enterprise risk management function that identifies, assesses, monitors, and

manages enterprise risk. Except as provided in subdivision (c) of this section, a domestic

insurer that is not a member of a holding company system, an article 16 system, or an

article 17 system also shall adopt such a formal enterprise risk management function. The

enterprise risk management function shall be appropriate for the nature, scale, and

complexity of the risk and shall adhere to the following, as relevant:

(1) have an objective enterprise risk management function headed by an appropriately

experienced individual with the requisite authority and who has access to the board of

directors, or if there is no board of directors, then the governing body, and senior

management;

(2) have a written risk policy adopted by the respective board or a committee thereof, or if

there is no board of directors, then the governing body, that delineates the insurer’s, holding

company system’s, article 16 system’s, or article 17 system’s risk/reward framework, risk

tolerance levels, and risk limits;

(3) provide a process for the identification and measurement of risk under a sufficiently

wide range of outcomes using techniques that are appropriate to the nature, scale, and

complexity of the risks the insurer, holding company system, article 16 system, or article

17 system bears and are adequate for capital management and solvency purposes;

(4) have a process of risk identification and measurement supported by documentation that

provides appropriately detailed descriptions and explanations of risks identified, the

measurement approaches used, key assumptions made, and outcomes of any plausible

adverse scenarios that were run;

9

(5) use prospective solvency assessments, including scenario analysis and stress testing;

(6) incorporate risk tolerance levels and limits in the policies and procedures, business

strategy, and day-to-day strategic decision-making processes;

(7) consider a risk and capital management process to monitor the level of financial

resources relative to economic capital and regulatory capital requirements;

(8) incorporate investment policy, asset-liability management policy, effective controls on

internal models, longer-term continuity analysis, and feedback loops to update and improve

the enterprise risk management function continuously;

(9) address all reasonably foreseeable and relevant material risks including, as applicable,

insurance, underwriting, asset-liability matching, credit, market, operational, reputational,

liquidity, and any other significant risks;

(10) include an assessment that identifies the relationship between risk management and

the level and quality of financial resources necessary as determined with quantitative and

qualitative metrics; and

(11) identify, quantify, and manage any risks to which the insurer may be exposed by

transactions or affiliations with any other member of the holding company system, article

16 system, or article 17 system of which the insurer is a member.”

Further, Insurance Circular Letter No. 14 (2011), states in part:

“Given the importance of risk management, the Department of Financial Services

(“Department”) expects every insurer to adopt a formal Enterprise Risk Management

(“ERM”) function. An effective ERM function should identify, measure, aggregate, and

manage risk exposures within predetermined tolerance levels, across all activities of the

enterprise of which the insurer is part, or at the company level when the insurer is a stand-

alone entity.”

In accordance with Insurance Regulation No. 203 (11 NYCRR 82) “Enterprise Risk

Management and Own Risk and Solvency Assessment,” as of June 25, 2014, the Company’s

ultimate parent, Thrive Partners III GP, LLC, is required to adopt a formal enterprise risk

management function to proactively identify and mitigate various business risks, including

prospective business risks. However, no such ERM framework was in place during the

examination period. One has subsequently been put into place.

10

It is recommended that the Thrive Partners III GP, LLC Companies, which include Oscar

NY, comply with Part 82.2(a) of Insurance Regulation No. 203 (11 NYCRR 82) by adopting a

formal enterprise risk management function.

C. Internal Audit

The Company does not have a formal internal audit function. Such a function can provide

independent assurance that Oscar NY’s risk management, governance and internal control

processes are operating effectively by providing an independent, unbiased assessment of the

Company’s operations.

It is recommended, as a best practice, that the Company establish an internal audit function

in order to provide an independent, unbiased assessment of the Company’s operations.

D. Territory and Plan of Operation

Oscar NY offers coverage using an Exclusive Provider Organization (“EPO”) product that

provides individual health benefits to its members through both a leased and Oscar NY-contracted

provider network of over 40,000 providers, including over 70 hospitals. Oscar NY’s service area

includes the nine downstate New York counties: Suffolk, Nassau, Westchester, Rockland,

NewYork, Kings, Queens, Richmond, and the Bronx. Oscar NY also offers health insurance

benefits through the New York State of Health (“NYSOH”), the state-run marketplace, as a

Qualified Health Plan. In New York State, the NYSOH is coordinated through the New York State

Department of Health.

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Oscar NY entered the small group market in 2017 with "Oscar for Business," offering

health insurance policies to New York small groups with between 1 and 100 employees. Oscar for

Business sales launched in February 2017 for its first policies effective on April 1, 2017. The

product is currently available in New York City and Long Island.

E. Reinsurance

Effective January 1, 2015, Oscar Insurance Corporation entered into a Medical per Person

Excess of Loss Reinsurance Agreement with PartnerRe America Insurance Company. The policy

is written and renewable annually.

Effective Period Oscar’s Retention Reinsurer’s Liability

1/01/15 thru $350,000 annually 90% of all qualifying losses

1/01/16 per member. to Oscar.

The agreement includes an insolvency clause in accordance with New York Insurance Law

Sections 1308(a)(2)(A)(i) and (ii). Either party may terminate the agreement upon thirty days’

notice, with such notice also given to the Department.

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F. Holding Company System

The Company is part of a holding company system as depicted in the following

organizational chart as of December 31, 2015:

JOSHUA KUSHNER VARIOUS MEMBERS *

MULBERRY MANAGEMENT

CORPORATION

(DE CORPORATION)

MULBERRY HEALTH, INC.

(DELAWARE CORPORATION)

(100%)

OSCAR INSURANCE

CORPORATION

(NY CORPORATION)

THRIVE PARTNERS III, GP,

LLC

(DELAWARE LIMITED

LIABILITY COMPANY)

VARIOUS LIMITED

PARTNERS **

THRIVE CAPITAL PARTNERS III, LP,

(DELAWARE LIMITED)

PARTNERSHIP)

(25.71% Issued & Outstanding Stock;

61.4% Voting Securities)

VARIOUS INDIVIDUALS &

ENTITIES ***

OSCAR HEALTH AGENCY

(NY CORPORATION)

OSCAR HEALTH PLAN OF

CALIFORNIA

(CA CORPORATION)

OSCAR INSURANCE

COMPANY OF TEXAS

(TX CORPORATION)

OSCAR INSURANCE

CORPORATION OF NEW

JERSEY

(NJ CORPORATION)

* No such member has limited Liability company interests in Thrive Partners III GP, LLC that represent

10% or more voting control of Thrive Partners III GP, LLC

** Such Limited partners are passive investors and do not control Thrive Capital Partners III, L.P.

*** No such individual or entity controls 10% or more of Mulberry’s voting securities.

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Thrive Partners III GP, LLC (“Thrive GP”) is a venture capital fund manager formed on

August 15, 2012, and organized as a limited liability company under the laws of Delaware. Joshua

Kushner is the majority member and Managing Director of Thrive GP.

Thrive Capital Partners III, LP (“Thrive LP”) is a venture capital fund formed on August

15, 2012, and organized as a limited partnership under the laws of Delaware. Thrive LP has more

than 90% of the voting control of Mulberry Health, Inc.

Joshua Kushner is deemed the ultimate controlling person in Oscar’s holding company

system because he represents more than 90% voting control and is the majority member of Thrive

GP, the general partner of Thrive LP.

Mulberry Health, Inc. is a Delaware corporation incorporated on October 25, 2012.

Mulberry operates as the direct parent of Oscar NY. Its principal offices are located at 295

Lafayette Street, New York, NY 10012.

Management Services Agreement

In 2015, the Company filed with the Department the following:

 A Proposed Shared Services Agreement;

 A Tax Allocation Agreement; and,

 A Request to transfer an asset consisting of intellectual property to its affiliate,

Mulberry Management Corporation.

On July 5, 2017, the Department issued a non-objection for the Tax Allocation Agreement.

The other agreements/transactions are currently under review by the Department.

14

G. Significant Operating Ratios

The following schedule reflects the Company’s operating results:

Year

Net Premiums

Written

Net Paid

Health Claims Net Income

Policyholder

Surplus

Ratio of Net

Premiums Written

to Surplus

2015 $117,421,763 $134,353,000 ($92,453,335) $21,280,563 551.7%

2014 $ 56,921,211 $ 55,224,814 ($27,561,270) $27,282,554 208.6%

2013 0 $ 0 ($ 8,165,499) $46,574,657 -

The underwriting ratios for 2015 are presented below on an earned-incurred basis:

Amounts Ratios

Claims $ 152,039,918 129.5%

Claim adjustment expenses 10,818,001 9.2%

General administrative expenses 35,714,998 30.4%

Increase in reserves for health contracts 11,302,659 9.6%

Net underwriting gain (loss) (92,453,813) (78.7)%

Premium revenue $117,421,763 100.00%

The Company’s authorized control level Risk-Based Capital (“RBC”) was $8,010,121 as

of December 31, 2015. Its total adjusted capital was $21,280,563, yielding an RBC ratio of 265.7%

at December 31, 2015.

H. Allocation of Expenses

Part 109.2 of Insurance Regulation 30 (11 NYCRR 109.2), states:

“(a) Direct allocations.

Wherever possible, salaries of individuals or similarly employed groups shall be

allocated direct to companies, expense groups and primary lines of business. In other

words, salaries of employees whose work is solely in connection with a specific

company, expense group or primary line of business shall be allocated thereto.

(b) Allocations other than direct.

(1) When a direct allocation is not made, salaries, with certain exceptions hereinafter

noted, shall be allocated on whichever of the following bases, or combinations thereof,

15

are appropriate: Number of items or units, time studies, overhead on other allocations,

premiums, dollar volume of losses, other special studies.

(2) The effects of the application to each operating expense classification of all bases of

allocation shall be shown on records kept in clear and legible form. Such records shall

be readily available for examination.”

During the examination period, Oscar NY paid salaries and other expenses for its affiliates

and was subsequently reimbursed by those entities. The calculation of the reimbursement amounts

were tested, in order to determine compliance with Insurance Regulation 30 (11 NYCRR 109.2).

During the examiner’s revew, it was noted that the breakout of employee salaries was performed

by a polling of Oscar-NY’s employees, instead of through a method approved by the cited

Regulation.

It is recommended that the Company comply with Part 109.2 of Insurance Regulation 30

(11 NYCRR 109.2) with regard to utilizing an acceptable methodology for determining the

allocation of expenses.

Additionally, Part 106.6 of Insurance Regulation 30 (11 NYCRR 106.6), states:

“(a) The methods followed in allocating joint expenses shall be described, kept and

supported as set forth under “detail of allocation bases” (see section 109.4[g], infra).

(b) The effects of the application, to each operating expense classification of all bases of

allocation shall be shown on records kept in clear and legible form. Such records shall

be readily available for examination.”

The lack of a formal structure and documentation supporting the allocations is not in

compliance with Part 106.6 of Insurance Regulation 30, cited above.

16

It is recommended that the Company comply with Part 106.6 of Insurance Regulation 30

(11 NYCRR 106.6) by maintaining documentation supporting its allocation and keep such records

available for examination.

I. Medical Loss Ratio Reporting

The Company’s 2015 Medical Loss Ratio (“MLR”) Annual Reporting Form was reviewed

to determine compliance with Title 45 of the U.S. Code Federal Regulations (45 CFR

§158.110(b)), which implements section 2718 of the Public Health Service Act (“PHS Act”).

Section 2718 of the PHS Act, as added by the Affordable Care Act (“ACA”), generally requires

health insurance companies to submit to the Secretary an annual report on their MLRs. The MLR

is the proportion of premium revenue expended by a company on clinical services and activities

that improve health care quality in a given state and market. Section 2718 of the PHS Act also

requires a company to provide rebates to consumers if it does not meet the MLR standard of 80%

in the Individual Market.

This is the first examination of the Company’s MLR Annual Reporting Forms. The

examination covered the reporting period of January 1, 2014 through December 31, 2015.

The examination was conducted in accordance with the Medical Loss Ratio Examination

Handbook (the “MLR Handbook”). The MLR Handbook sets forth the guidelines and procedures

for planning and performing an examination to evaluate the validity and accuracy of the data

elements and calculated amounts reported on the MLR Reporting Form, and the accuracy and

timeliness of any rebate payments. The examination included assessing the principles used and

significant estimates made by the Company, evaluating the reasonableness of expense allocations,

17

and determining compliance with relevant statutory accounting standards, MLR regulations and

guidance, and the MLR Reporting Form Filing Instructions.

Title 45 of the U.S. Code Federal Regulations (45 CFR §158.110(b)) requires that a report

for each Medical Loss Ratio reporting year is to be submitted to the Secretary of the U.S.

Department of Health and Human Services (“HHS”) by July 31

st

of the year following the end of

an MLR reporting year, on a form and in the manner prescribed by the Secretary of HHS. Based

on the examiner’s review, Oscar NY filed an acceptable form by June 1, 2016 for the 2015

reporting year and is in compliance with Title 45 CFR §158.110(b).

Title 45 CFR §158.210 (c) requires that an issuer must provide a rebate to enrollees if the

issuer has an MLR of less than 80% for the individual market. The Company’ MLR and rebate

calculations from the MLR Annual Reporting Form were as follows:

MLR Components

Individual

Adjusted Incurred Claims

$

248,207,453

Plus

:

Quality Improvement Expenses 6,677,221

Cost

-

sharing adjustments

(8,084,077)

F

ederal Transitional Reinsurance Program

payments (37,302,888)

Expected Federal Risk Adjustment Pro

g

ram

payments 39,050,905

Federal Risk Corridors Program net payments

(

1,011

,

926

)

MLR Numerator

$

247,536,688

Premium Earned

219,640,913

Less

:

Federal & State Taxes and Licensing/Regulatory Fees 8,825,852

MLR Denominator

$

210,815,061

Preliminary MLR Before Credibility Adjustment

117.5%

18

Credibility Adjustment

1.2%

Credibility

–

Adjusted MLR

118.7

%

MLR Standard

8

0

%

Rebate Amount

$0

Medical Loss Ratio Numerator

According to Title 45 of the U.S. Code of Federal Regulations (CFR §158.221(b)), the

numerator of the Medical Loss Ratio (MLR) calculation is comprised of incurred claims, as

defined in 45CFR §158.140, plus expenditures for activities that improve health care quality, as

defined in Title 45 CFR §158.150, and Title 45 CFR §158.151. The examiner verified the data

used to calculate the adjusted incurred claims. Based on the review, Oscar NY included

appropriate adjusted incurred claims in the MLR numerator.

Section 243.2 of Insurance Regulation 152 (11 NYCRR 243.2) states in part:

“(a) In addition to any other requirement contained in Insurance Law, Section 325, any

other section of the Insurance Law or other law, or any other provision of this Title, every

insurer shall maintain its claims, rating, underwriting, marketing, complaint, financial,

and producer licensing records, and such other records subject to examination by the

superintendent, in accordance with the provisions of this Part…

(4) A claim file for six calendar years after all elements of the claim are resolved and

the file is closed or until after the filing of the report on examination in which the claim

file was subject to review, whichever is longer. A claim file shall show clearly the

inception, handling and disposition of the claim, including the dates that forms and

other documents were received.”

The examiner reviewed the reasonableness of the health care quality improvement

expenses including confirming that the methodology complies with the narrative provided within

the Part 4 – Expense Allocation portion of the MLR Reporting Form and conforms to the definition

of Healthcare Quality Improvement Expenses as defined by 45 CFR §158.150, and 45 CFR

§158.151. Based on the examiner’s review, Oscar NY’s allocation methodology and health care

19

quality improvement expenses reported in the MLR numerator do not conform to the regulations.

Instead, the Company allocated Quality Improvement expenses utilizing data from a prior period

and was not able to provide any support for the propriety of those percentages.

It is recommended that the Company comply with Title 45 CFR §158.150, and Title 45

CFR §158.151 by establishing Quality Improvement expenses using current allocation percentages

for each MLR filing. It is further recommended that the Company comply with Part 243.2 of

Insurance Regulation 152 (11 NYCRR 243.2) by maintaining records to verify the accuracy of the

allocation percentages. It is noted that this deficiency did not have any impact on the Company’s

liability to pay rebates as the final ratio was above the minimum and utilizing proper allocations

would have served to further increase the percentage.

Medical Loss Ratio Denominator

According to Title 45 CFR §158.22(c), the denominator of the MLR calculation is

comprised of premium revenue, as defined in Title 45 CFR §158.130, minus federal and state taxes

and licensing and regulatory fees, described in Title 45 CFR §158.161(a), and Title 45 CFR

§158.162(a)(1) and (b)(1). The examiner verified the data used to calculate the premium revenue.

Based on the review, Oscar NY included appropriate premiums earned in the MLR denominator.

Credibility Adjustment

According to Title 45 CFR§158.232, the credibility adjustment is the product of the base

credibility factor multiplied by the deductible factor. This calculation was tested and it was

determined to be accurate.

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Credibility Adjusted Medical Loss Ratio

According to Title 45 CFR §158.221(a), the calculation of the MLR is the ratio of the

numerator to the denominator, subject to the applicable credibility adjustment, if any. Based on

the examiner’s review, Oscar NY appropriately calculated the medical loss ratio for its market

segment.

Rebate Amount, Calculation and Distribution

According to Title 45 CFR §158.240, a rebate is required if an insurer’s MLR is less than

the minimum MLR standard. Based on the examiner’s review, Oscar NY’s MLR exceeded the

minimum percentage for its market segments. As a result, no rebates were warranted for issuance

during the examination period.

MLR Information Notice

According to Title 45 of the U.S. Code of Federal Regulation §158.251(a) and (b), a notice

of rebate is required when the medical loss ratios do not exceed the minimum percentage. The

Company’s medical loss ratio for the examination period did exceed the minimum percentage and

therefore no notices were required.

Impact On Risk-Based Capital

According to Title 45 of the U.S. Code of Federal Regulations §158.270(a), rebate

payments having any adverse impact on the Company’ Risk-Based Capital (“RBC”) level requires

notification by the Regulator to the Secretary of the U.S. Department of Health and Human

21

Services (“HHS”). Based on the examiner’s review, the Company’s MLR exceeded the minimum

percentage for the individual market segments, and no rebates were due to be issued, therefore

there was no impact on the RBC level that would warrant notification to the Secretary of HHS.

3. FINANCIAL STATEMENTS

The following statements show the assets, liabilities, and surplus as of December 31, 2015,

as contained in the Company’s 2015 filed annual statement, a condensed summary of operations

and a reconciliation of the surplus account for each of the years under review. The examiner’s

review of a sample of transactions did not reveal any differences which materially affected the

Company’s financial condition as presented in its financial statements contained in the December

31, 2015 filed annual statement.

Independent Accountants

As noted previously in this report, the firm of Deloitte & Touche LLP was retained by the

Company to audit the Company’s combined statutory basis statements of financial position as of

December 31st of the examination period, and the related statutory-basis statements of operations,

capital and surplus, and cash flows for the year then ended. D&T concluded that the statutory

financial statements presented fairly, in all material respects, the financial position of the Company

at the respective audit dates.

22

A. Balance Sheet

Assets

Bond $ 300,000

Cash and short-term investments 85,209,163

Uncollected premiums in the

course of collection 266,620

Amounts recoverable from reinsurer 16,329,237

Electronic data processing equipment 129,281

Receivable from parent and affiliates 13,551,816

Health care receivable 2,628,434

Risk corridor receivable * 165,256

Total assets $ 118,579,807

Liabilities

Claims unpaid $ 33,567,630

Accrued medical incentive pool 1,795,119

Unpaid claims adjustment

Expenses 729,193

Aggregate health policy reserves 12,659,214

Aggregate health policy reserves 1,357,248

Premiums received in advance 8,092,456

Ceded reinsurace premiums payable 2,105,411

General expenses due and accrued 6,819,327

Aggregate write-ins for other liabilities 30,173,646

Total liabilities $ 97,299,244

Capital and Surplus

Capital stock $ 200,000

Aggregate write-in for special surplus funds 2,229,556

Gross paid in and contributed

surplus 152,228,154

Unassigned funds (133,377,147)

Total capital and surplus $ 21,280,563

Total liabilities, capital and surplus $ 118,579,807

The Internal Revenue Service did not audit the tax returns filed by the Company for

the period under examination. The examiner is unaware of any potential exposure of

the Company to any further tax assessment and no liability has been established herein

relative to such contingency

.

23

The Risk Corridor Receivable balance was recorded at approximately 12.6% of the

$9,342,724 that had been calculated to be received under the federal program. The

amount actually received, subsequent to the examination, was $1 million.

B. Statement of Revenue and Expenses and Capital and Surplus

Capital and Surplus decreased $14,719,437 during the examination period, June 12, 2013,

through December 31, 2015, detailed as follows:

Revenue

Net premium income $ 174,342,974

Aggregate write-ins 0

Total revenue

Hospital and Medical Expenses

Hospital/medical benefits $ 194,954,393

Other professional services 10,511,380

Emergency room and out-of-area 2,192,898

Prescription drugs 36,687,514

Incentive pool, withhold adjustments 1,795,119

Net reinsurance recoveries (40,279,808)

Total hospital and medical expenses $ 205,861,496

Administrative expenses

Claims adjustment expenses 15,830,738

General administrative expenses 68,172,245

Increase in reserves for A&H

contracts 12,659,215

Total underwriting deductions

Net underwriting loss

Net investment income earned

Net loss before taxes

Federal income taxes

Net loss

$ 174,342,974

$ 302,523,694

$ (128,180,720)

616

$ (128,180,104)

0

$ (128,180,104)

24

Changes in Capital and Surplus

Capital and surplus per report on organization

examination as of June 12, 2013 $36,000,000

Increases

Net income (loss) $

0

Paid in Capital 116,428,154

Change in non-admitted assets

Aggragate write-ins for gains or (losses)

Decreases

$128,180,104

2,967,085

402

Net increase (decrease) in surplus ($14,719,437)

Capital and surplus, per examination, as of December

31, 2015 $21,280,563

Capital Infusions

Sections 1505(c) and (d)(1)(A) of the New York Insurance Law state:

(c) The superintendent's prior approval shall be required for the following transactions

between a domestic controlled insurer and any person in its holding company system:

sales, purchases, exchanges, loans or extensions of credit, or investments, involving five

percent or more of the insurer's admitted assets at last year-end.

(d) The following transactions between a domestic controlled insurer and any person in

its holding company system may not be entered into unless the insurer has notified the

superintendent in writing of its intention to enter into any such transaction at least thirty

days prior thereto, or with regard to reinsurance treaties or agreements at least forty-five

days prior thereto, or such shorter period as the superintendent may permit, and the

superintendent has not disapproved it within such period:

(1) sales, purchases, exchanges, loans or extensions of credit, or investments involving

less than five percent of the insurer's admitted assets at last year-end, provided the

transactions are equal to or exceed:

Since its inception, the Company has experienced sustained and significant financial

operating losses. As a result, the Company received $251,302,154 in capital infusions from its

Parent since licensure. Infusions include $102,302,154 during the period covered by this

examination and an additional $204,900,000 during 2016 and 2017. It is noted that, as a condition

for licensing, Mulberry Health, Inc.s’ board of directors committed to ensuring that Oscar’s

business writings be limited to a net premium to surplus ratio of not more than 4:1, and not more

25

than 8:1 for Exclusive Provider Organization (“EPO”) products. In addition to other statutory

requirements, these ratios serve as the basis for the capital infusions made by the Parent to the

Company, which has resulted in the Company complying with

date. Below are the details of those capital infusions:

2013 to 2015

November 11, 2013

March 1, 2014

November 18, 2014

December 17, 2014

December 31, 2014

February 2, 2015

March 30, 2015

November 9, 2015

December 10, 2015

December 31, 2015

TOTAL

Contribution

5,878,554

250,000

3,500,000

5,000,000

673,600

5,000,000

10,000,000

31,000,000

12,000,000

29,000,000

2016 to 2017

January 29, 2016

February 29, 2016

March 31, 2016

May 27, 2016

June 30, 2016

November 7, 2016

December 6, 2016

December 27, 2016

April 25, 2017

May 26, 2017

August 11, 2017

June 28, 2017

July 31, 2017

September 26, 2017

October 23, 2017

November 29, 2017

December 12, 2017

capital requirements to

Contribution

$30,000,000

17,000,000

21,000,000

9,500,000

27,000,000

12,000,000

16,500,000

16,000,000

7,000,000

2,900,000

5,800,000

9,800,000

2,300,000

7,700,000

6,100,000

4,000,000

10,300,000

$204,900,000 $102,302,154

It is noted that the contributions received prior to 2015 and some that were contributed in

2017 were not submitted for approval to the Superintendent, as required by Sections 1505(c) and

(d)(1)(A) of the New York Insurance Law.

26

4. CLAIMS UNPAID AND UNPAID CLAIM ADJUSTMENT EXPENSES

The examination Claims Unpaid liability of $33,567,630 is the same as the amount

reported by the Company, as of December 31, 2015.

The examination Unpaid Claims Adjustment Expense liability of $729,193 is the same

amount reported by the Company, as of December 31, 2015.

The examination analysis of the captioned accounts was conducted in accordance with

generally accepted actuarial principles and practices and was based on statistical information

contained in the Company’s internal records and in its filed annual statements, as well as additional

information provided by the Company, as verified by the examiners. The examination reserve was

based upon actual payments made through a point in time, plus an estimate for claims remaining

unpaid at that date. Such estimate was calculated based on actuarial principles which utilized the

Company’s experience in projecting the ultimate cost of claims incurred on or prior to December

31, 2015.

27

5. MARKET CONDUCT ACTIVITIES

In the course of this examination, a review was made of the manner in which the Company

conducts its business practices and fulfills its contractual obligations to policyholders and

claimants. The review was general in nature and is not to be construed to encompass the more

precise scope of a market conduct examination. The review was directed at the practices of the

Company in the following major areas:

A. Explanation of benefits statements

B. Utilization review

C. Utilization review appeal

D. Prompt payment of claims

A. Explanation of Benefits Statements

Section 3234 of the New York Insurance Law states in part:

“(a) Every insurer, including health maintenance organizations operating under article

forty-four of the public health law or article forty-three of this chapter and any other

corporation operating under article forty-three of this chapter, is required to provide the

insured or subscriber with an explanation of benefits form in response to the filing of any

claim under a policy or certificate providing coverage for hospital or medical expenses,

including policies and certificates providing nursing home expense or home care expense

benefits.

(b) The explanation of benefits form must include at least the following…

(7) a telephone number or address where an insured or subscriber may obtain clarification

of the explanation of benefits, as well as a description of the time limit, place and manner

in which an appeal of adenial of benefits must be brought under the policy or certificate

and a notification that failure to comply with such requirements may lead to forfeiture of

a consumer's right to challenge a denial or rejection, even when a request for clarification

has been made.”

28

It was noted that none of the explanation of benefits were in compliance with Section

3234(b)(7) of the New York Insurance Law for their failure to include notification that failure to

comply with the stated appeal/grievance requirements may lead to forfeiture of a consumer’s right

to challenge a denial or rejection, even when a request for clarification has been made. A review

revealed there were 158,724 such EOBs during 2015, all of which were in violation.

It is recommended that the Company comply with Section 3234(b)(7) of the New York

Insurance Law by including all required information on its explanation of benefits statements.

B. Utilization Review

Section 4903 of the New York Insurance Law states in part:

“(b)(1) A utilization review agent shall make a utilization review determination involving

health care services which require pre-authorization and provide notice of a

determination to the insured or insured's designee and the insured’s health care provider

by telephone and in writing within three business days of receipt of the necessary

information…

(c) A utilization review agent shall make a determination involving continued or

extended health care services… and shall provide notice of such determination to the

insured or the insured's designee, which may be satisfied by notice to the insured’s health

care provider, by telephone and in writing within one business day of receipt of the

necessary information

(d) A utilization review agent shall make a utilization review determination involving

health care services which have been delivered within thirty days of receipt of the

necessary information.

(e) Notice of an adverse determination made by a utilization review agent shall be in

writing and must include:

(1) the reasons for the determination including the clinical rationale, if any;

(3) …Such notice shall also specify what, if any, additional necessary information must

be provided to, or obtained by, the utilization review agent in order to render a decision

on the appeal.”

29

Adverse Determination Letters sent by Oscar NY’s third-party administrator AliCare for

post-service claims during 2015 were in violation of New York Insurance Law Section 4903(e)(1)

for their failure to include a clinical rationale when the claim was denied for a lack of sufficient

information or when the information that was provided did not justify the level of care. Nor did

the adverse determination letters indicate what additional information would be required to

overturn the denial; which is also a violation of the cited law.

The examiner reviewed twenty claims that had been denied retrospectively for a lack of

medical necessity during the exam period. The sample was selected from the population of

hospital/medical claims adjudicated during 2015 by Alicare. The following issues were noted

from a review of claims within the sample:

 In violation of Section 4903(e)(1) of the New York Insurance Law, there were

ten instances, where the claims did not contain a sufficiently detailed

explanation of the clinical rationale for why the claim had been denied and three

instances where the cause for denial on the Adverse Determination letter was

listed incorrectly. According to the Company, this occurred when the claim

was being denied for a lack of sufficient information or when the information

that was provided did not justify the level of care.

 There were three claims where an authorization was created retroactive to the

adjudication of the claim but the claim was not re-opened for payment until

discovery during the retrospective review.

It is recommended that the Company comply with New York Insurance Law Section

4903(e)(1) by ensuring that all Adverse Determinations include an accurate and sufficiently

detailed clinical rationale for the denial.

It is recommended that the Company ensure that, where authorizations for treatment are

provided retroactive to the adjudication of a claim, the originally denied claims are overturned for

30

payment, and where applicable, interest be paid, pursuant to New York Insurance Law Section

3224-a(c).

Additional issues that were noted within the sample that did not relate directly to

Utilization Review, are as follows:

 Eight of the claim decisions were made late, in violation of New York Insurance

Law 3224-a. In one instance, interest was not paid on a late claim, as required by

New York Insurance Law 3224-a(c). Prompt payment violations are discussed

in more detail in a separate section of this report.

 In five instances, Explanation of Benefit documents were sent for claims that had

been adjusted but the new documents did not contain any notification that the new

EOBs were replacements of the prior documents. This can lead to confusion on

the part of the insured.

It is recommended, as a best practice, that when a claim has been adjusted, the subsequent

Explanation of Benefits statement include notification that the EOB is an adjustment, in order to

assist the member in understanding the adjudication of the claim.

The examiner also tested a sample of prospective, concurrent, and retrospective decisions

that were selected from the Company’s Utilization Review logs from the period January 1, 2015

through December 31, 2015. Twenty-five such cases were selected.

Of the twelve prospective requests for treatment in the sample, in one instance, the decision

was not made within three business days, as required by New York Insurance Law Section

4903(b).

Of the six concurrent requests for treatment in the sample, in two instances, the decision

was not made within one business day, as required by New York Insurance Law Section 4903(c).

During discussion concerning the results of this testing, the Company indicated that,

effective January 1, 2016, it had brought the utilization management function previously delegated

31

to Alicare in-house in order to improve quality and reduce expenses. In order to determine the

effectiveness of the change, a statistically valid sample of 200 UR decisions from the population

of 12,564 decisions that were made during 2016 was selected to test for compliance with New

York Insurance Law Sections 4903(a), (b), and (c). The results of the testing revealed that twenty

decisions, or 10% of the total, were made outside the timing requirements of the law. An

extrapolation of this total indicates that a calculated error rate of 1,256 cases were in violation of

the cited law.

It is recommended that the Company comply with the provisions of New York Insurance

Law Section 4903 and make Utilization Review decisions within the required time frames after

receipt of the necessary information.

During the aforementioned reviews, the Company was not able to provide evidence of a

routine and formal program to test adjudicated claims for accuracy and timeliness.

It is recommended that the Company institute a program of regularly scheduled formal

audits of utilization review decisions and decision timeliness in order to reduce the number of

exceptions within its processes. While the Company has taken steps to increase the review of

adjudication quality and to increase the training of staff subsequent to the examination date, a

comprehensive auditing program has not been initiated.

C. Utilization Review Appeal

Section 4904(c) of the New York Insurance Law states in part:

“…The utilization review agent must provide written acknowledgment of the filing of

the appeal to the appealing party within fifteen days of such filing and shall make a

determination with regard to the appeal within sixty days of the receipt of necessary

32

information to conduct the appeal. The utilization review agent shall notify the insured,

the insured's designee and, where appropriate, the insured’s health care provider, in

writing of the appeal determination within two business days of the rendering of such

determination.”

Section 4904(d) of the New York Insurance Law states in part:

“Both expedited and standard appeals shall only be conducted by clinical peer reviewers,

provided that any such appeal shall be reviewed by a clinical peer reviewer other than

the clinical peer reviewer who rendered the adverse determination.”

Oscar NY provided the examiner with its log of appeals from the period January 1, 2015

through December 31, 2015, and the examiner selected twenty-two cases for review, in order to

determine compliance with New York Insurance Law Section 4904.

During review of the sample, the examiner noted the following, in violation of New York

Insurance Law Section 4904(c):

 In fourteen instances, Oscar NY failed to provide written acknowledgement

to the appealing party within fifteen days of an appeal filing;

 In two instances, Oscar NY did not make the appeal determination within

the required time frame of sixty days; and

 In seven instances, the Company did not send an appeal determination letter

to notify the insured/insured’s designee of the appeal determination within

two business days of making such determination.

Further, in fourteen instances, Oscar NY was not in compliance with New York Insurance

Law Section 4904(d), as the provider that made the appeal determination was the same clinical

peer reviewer that made the original denial.

It is recommended that Oscar NY comply with the provisions of Section 4904(c) of the

New York Insurance Law by ensuring that all of the timeliness requirements are achieved in its

appeal communications and determinations.

33

It is recommended that Oscar NY comply with the requirements of Section 4904(d) of the

New York Insurance Law by ensuring that the clinical peer reviewer who determines an appeal is

not the same clinical peer reviewer who rendered the original adverse determination.

D. Prompt Payment of Claims

Section 3224-a of the New York Insurance Law “Standards for prompt, fair and equitable

settlement of claims for health care and payments for health care services” requires all insurers to

pay undisputed claims within either 30 days or 45 days, depending upon whether the claim was

submitted electronically or on paper, respectively. Where a claim has been disputed, insurers are

required to notify the sender of the dispute in order to seek clarification within thirty days.

Section 3224-a(a) of the New York Insurance Law states:

“(a) Except in a case where the obligation of an insurer or an organization or corporation

licensed or certified pursuant to article forty-three or forty-seven of this chapter or article

forty-four of the public health law to pay a claim submitted by a policyholder or person

covered under such policy ("covered person") or make a payment to a health care

provider is not reasonably clear, or when there is a reasonable basis supported by specific

information available for review by the superintendent that such claim or bill for health

care services rendered was submitted fraudulently, such insurer or organization or

corporation shall pay the claim to a policyholder or covered person or make a payment

to a health care provider within thirty days of receipt of a claim or bill for services

rendered that is transmitted via the internet or electronic mail, or forty-five days of receipt

of a claim or bill for services rendered that is submitted by other means, such as paper or

facsimile.”

Section 3224-a(b) of the New York Insurance Law states in part:

“(b) In a case where the obligation of an insurer or an organization or corporation

licensed or certified pursuant to article forty-three or forty-seven of this chapter or article

forty-four of the public health law to pay a claim or make a payment for health care

services rendered is not reasonably clear due to a good faith dispute regarding the

eligibility of a person for coverage, the liability of another insurer or corporation or

organization for all or part of the claim, the amount of the claim, the benefits covered

under a contract or agreement, or the manner in which services were accessed or

provided, an insurer …shall pay any undisputed portion of the claim in accordance with

this subsection and notify the policyholder, covered person or health care provider in

writing within thirty calendar days of the receipt of the claim:

34

(1) that it is not obligated to pay the claim or make the medical payment, stating the

specific reasons why it is not liable; or

(2) to request all additional information needed to determine liability to pay the claim or

make the health care payment…”

During calendar year 2015, Oscar NY utilized multiple claim systems for its various claim

types: medical/hospital, mental health, vision, and pharmacy claims. To test Oscar NY’s

compliance with the aforementioned laws, claims paid during calendar year 2015 from the various

systems were sampled and tested. First, claims were “rolled up” so that each claim submitted was

only represented a single time. Claims from each population that appeared to be violations of Parts

(a) and (b) of the New York Insurance Law Section 3224-a were extracted into separate

populations for testing. From there, statistical samples were selected and those samples were

tested to determine compliance with the aforementioned statute.

For the population of claims from the system containing medical/hospital claims, the

sampling revealed there were 13,994 claims that were adjudicated late. For this single population,

this resulted in a violation rate of 4.9%.

It is recommended that the Company comply with Section 3224-a of the New York

Insurance Law and strive to adjudicate all claims within the time frames prescribed under the law.

35

6. SUMMARY OF COMMENTS AND RECOMMENDATIONS

ITEM PAGE NO.

A. Subsequent Changes to the Board of Directors

It is recommended as a best practice and as suggested by the NAIC

Examiner’s Handbook, that the Company include a fair

representation of independent members on its board of directors.

8

B. Enterprise Risk Management

It is recommended that the Thrive Partners III GP, LLC Companies,

which include Oscar NY, comply with Part 82.2(a) of Insurance

Regulation No. 203 (11 NYCRR 82) by adopting a formal enterprise

risk management function.

10

C. Internal Audit

It is recommended, as a best practice, that the Company establish an

internal audit function in order to provide an independent, unbiased

assessment of the Company’s operations.

10

D. Allocation of Expenses

i.

It is recommended that the Company comply with Part 109.2 of

Insurance Regulation 30 (11 NYCRR 109.2) with regard to utilizing

an acceptable methodology for determining the allocation of

expenses.

15

ii. It is recommended that the Company comply with Part 106.6 of

Insurance Regulation 30 (11 NYCRR 106.6) by maintaining

documentation supporting its allocation and keep such records

available for examination.

16

36

ITEM PAGE NO.

E. Medical Loss Ratio Reporting

It is recommended that the Company comply with Title 45 CFR

§158.150, and Title 45 CFR §158.151 by establishing Quality

Improvement expenses using current allocation percentages for each

MLR filing. It is further recommended that the Company comply

with Part 243.2 of Insurance Regulation 152 (11 NYCRR 243.2) by

maintaining records to verify the accuracy of the allocation

percentages. It is noted that this deficiency did not have any impact

on the Company’s liability to pay rebates as the final ratio was above

the minimum and utilizing proper allocations would have served to

increase the percentage.

19

F. Explanation of Benefit Statements

It is recommended that the Company comply with Section

3234(b)(7) of the New York Insurance Law by including all required

information on its explanation of benefits statements.

28

G. Utilization Review

i. It is recommended that the Company comply with New York

Insurance Law Section 4903(e)(1) by ensuring that all Adverse

Determinations include an accurate and sufficiently detailed clinical

rationale for the denial.

29

ii. It is recommended that the Company ensure that, where

authorizations for treatment are provided retroactive to the

adjudication of a claim, the originally denied claim are overturned

for payment, and where applicalbe, interest be paid, pursuant to New

York Insurance Law 3224-a(c).

30

37

ITEM PAGE NO.

iii. It is recommended, as a best practice, that when a claim has been

adjusted, the subsequent Explanation of Benefits statement include

notification that the EOB is an adjustment, in order to assist the

member in understanding the adjudication of the claim.

30

iv. It is recommended that the Company comply with the provisions of

New York Insurance Law Section 4903 and make Utilization

Review decisions within the required time frames after receipt of the

necessary information.

31

v. It is recommended that the Company institute a program of regularly

scheduled formal audits of utilization review decisions and decision

timeliness in order to reduce the number of exceptions within its

processes. While the Company has taken steps to increase the

review of adjudication quality, and to increase the training of staff

subsequent to the examination date, a comprehensive auditing

program has not been initiated.

31

H. Utilization Review Appeal

i. It is recommended that Oscar NY comply with the provisions of

Section 4904(c) of the New York Insurance Law by ensuring that all

of the timeliness requirements are achieved in its appeal

communications and determinations.

32

ii. It is recommended that Oscar NY comply with the requirements of

Section 4904(d) of the New York Insurance Law by ensuring that

the clinical peer reviewer who determines an appeal is not the same

clinical peer reviewer who rendered the original adverse

determination.

33

I. Prompt Payment of Claims

It is recommended that the Company comply with Section 3224-a of

the New York Insurance Law and strive to adjudicate all claims

within the time frames prescribed under the law.

34

______________________

_________________________

Respectfully submitted,

Froilan Estebal

Senior Insurance Examiner

STATE OF NEW YORK )

) SS

)

COUNTY OF NEW YORK)

Froilan Estebal, being duly sworn, deposes and says that the foregoing report

submitted by him is true to the best of his knowledge and belief.

Froilan Estebal

Subscribed and sworn to before me

this ________ day of___________