DocketNumber: Docket No. 3075-80
Citation Numbers: 86 T.C. 298, 1986 U.S. Tax Ct. LEXIS 145, 86 T.C. No. 20
Judges: Shields
Filed Date: 3/10/1986
Status: Precedential
Modified Date: 11/14/2024
*145
*299 *147 Respondent determined deficiencies in petitioner's Federal income taxes as follows:
Year | Deficiency |
1972 | $ 1,935,682.54 |
1973 | 397,760.23 |
1974 | 193,267.27 |
1975 | 483,091.21 |
After a number of concessions, the issues remaining are: (1) Whether petitioner properly computed its claim reserves on certain accident and health policies during the years in issue; (2) whether respondent's disallowance of a portion of petitioner's deductions for claim reserves was so arbitrary and unreasonable as to shift the burden of going forward with the evidence with respect to the correct amount of the reserves to respondent; and (3) if the deduction for claim reserves in 1972 is found to be improper, whether petitioner is entitled to spread forward any adjustment for that year over the 10-year period provided by section 810(d). *148 FINDINGS OF FACT
Some of the facts have been stipulated by the parties and are so found. Their stipulation of settled issues, stipulation of facts, and supplemental stipulation of facts and the exhibits attached thereto are incorporated herein by reference.
Petitioner is Time Insurance Co. (Time). It is a stock life insurance company which was organized in 1910 under the *300 laws of Wisconsin, and during all relevant times had its principal office and place of business in Milwaukee. For each of the calendar years 1972 through 1975, Time filed with the Internal Revenue Service Center at Kansas City, Missouri, original, amended, and "corrected amended" income tax returns as a life insurance company taxable under sections 801 through 820. Each return consisted of a Form 1120L, attached supporting schedules, and a copy of Time's annual statement for the particular year on a form prescribed by the National Association of Insurance Commissioners (NAIC).
During the years under consideration, petitioner as a life insurance company was required by State law to file the NAIC annual statements on a calendar year basis with the insurance regulatory agency of each State in which it did*149 business. It was also required to file copies of such statements with and as part of its Federal income tax returns. The form for and the information required by the annual statements are prescribed by the NAIC, an organization of which the insurance commissioner, or other principal insurance executive, of every State is a member.
During 1972 through 1975, petitioner sold life insurance and accident and health insurance in 45 States, including Wisconsin. Its accident and health (A & H) policies included both disability income and medical reimbursement insurance. The dispute in this case is limited, however, to the A & H medical reimbursement policies, which in the industry are sometimes referred to as medical expense policies. This type of policy insures against certain specified financial losses suffered by the insured as a result of an injury or sickness. Such policies generally provide for payment by the insurance company, either directly or through reimbursement to the insured, of all or part of the insured's covered medical expenses. *150 For purposes of administering benefit claims and establishing claim reserves, petitioner, during the years under *301 consideration, divided its A & H medical reimbursement policies into the following categories: (1) Individual Guaranteed Renewable (GR) hospital/surgical (class 6); (2) Individual Guaranteed Renewable (GR) major medical (class 7); (3) Individual Optionally Renewable (OR) hospital/surgical (class G); (4) Individual Optionally Renewable (OR) major medical (class H); (5) Group policies. *151 in continuous effect so long as the premiums were paid, but either the group holder or petitioner could terminate the policy at the end of any policy year by giving 30 days written notice prior to the yearend. All of petitioner's reimbursement policies were of a "per cause" type as opposed to a "calendar year" type in that they provided benefits after the satisfaction of a deductible amount during the specified benefit periods (usually 2 or 3 years) arising from a TIME * * * does hereby insure * * * and agrees to pay the Insured for Covered Expenses * * * Each policy also contained a grace period of 30 or 31 days for premium payments which was typically set out as follows: A grace period of thirty-one days will be granted for the payment of each *302 premium falling due after the first premium, In the OR policies, the grace period did not apply if petitioner had given written notice of its intention not to renew the policy 30 days prior to the premium due date. However, such refusal to renew or any other cancellation or termination would be without prejudice to any claim arising while the policy was in force. In a typical GR hospital/surgical policy (Class 6), petitioner agreed to pay a percentage (usually 80 percent) of the first $ 2,000 of covered medical expenses and another percentage (usually 100 percent) of such expenses thereafter, up to a lifetime maximum aggregate. The covered expenses were also subject to a maximum daily benefit set out in a policy schedule. Under these policies, reoccurring hospitalizations or surgical procedures caused by the same injury*153 or sickness and separated by less than 90 days in some policies, and 180 days in other policies, were considered to be part of the same injury or sickness. A typical OR hospital/surgical policy (Class G), contained a deductible amount, a maximum daily reimbursement for hospital confinement, and a maximum hospital miscellaneous expense benefit for each separate injury or sickness. Petitioner also agreed to pay surgical expenses, up to a maximum amount, for each injury or sickness based on a schedule of surgical benefits. Successive surgical procedures for the same cause were treated as the same procedure when they were separated by less than 12 months. In a typical GR major medical policy (Class 7), petitioner agreed to reimburse the insured for covered expenses incurred with respect to each separate injury or sickness, over a deductible amount, during a specified benefit period. The reimbursement was subject to a maximum amount set out in a policy schedule. The benefit period was usually 2 or 3 years and began when the first eligible expense occurred that satisfied the policy's deductible amount. Expenses *303 from a new cause had*154 to satisfy a separate deductible amount before a benefit period for that cause was established. Petitioner's OR major medical policies (Class H) were similar to its GR major medical policies in all material respects, except that the option to renew was with petitioner. In a typical group policy petitioner agreed to pay hospital, miscellaneous, and other medical expenses, which exceeded a deductible amount, during a benefit period which usually lasted 2 years. The benefit period began on the date the policyholder incurred the first eligible expense which satisfied the policy's deductible amount. The payments were to be made in accordance with a benefit schedule and were not to exceed a maximum amount specified in the policy. Medical expenses for a separate injury or sickness were subject to a separate deductible amount and a separate benefit period. Group policies typically contained the following additional provision: EXTENSION OF BENEFITS: If the insurance of any Insured Member or dependent terminates because the insured leaves his employment, or ceases to be a member of the Group Holder while benefits are being paid hereunder, coverage will be*155 continued as long as the covered person is continuously and totally disabled from the injury, sickness, or complication of pregnancy causing such disability; but only for: (1) a period of ninety (90) days, or (2) until the covered person is no longer totally disabled whichever occurs earlier; subject to the provisions of the Master Policy. As required by State law, petitioner's group policies also provided extended maternity benefits where pregnancy commenced during the policy period. Under Wisconsin's Administrative Code sec. Ins. 6.51 (1976), the following extended benefit provisions were also made applicable to petitioner's group insurance: (6) EXTENSION OF BENEFITS. (a) Every group policy * * * must provide a reasonable provision for extension of benefits in the event of total disability at the date of discontinuance of the group policy or *304 contract during the continuance of total disability as required by the following paragraphs of this section. * * * (d) In the case of hospital or medical expense coverages other than dental and maternity expense, a reasonable extension of benefits or accrued liability provision is required. Such a provision will be considered reasonable*156 if it provides an extension of at least 12 months under major medical and comprehensive medical type coverages, and under other types of hospital or medical expense coverages provides either an extension of at least 90 days or an accrued liability for expenses incurred during a period of disability or during a period of at least 90 days In making a determination of whether a particular claim for benefits would be accepted or denied, as well as the extent of petitioner's liability for such a claim, petitioner relied upon all of the terms and conditions appearing in the applicable policy and law, including some or all of the provisions set forth above. Under its practice, benefits would normally be denied by petitioner if the covered expenses were incurred while the policy was On a claim-by-claim basis, petitioner sometimes determined that it was liable *157 for a limited amount of expense even though incurred while a policy was not in force. For instance, with respect to individual policies which are optionally renewable, the liability of an insurance company under such policies does not usually exist beyond the specified term if the company refuses to renew the policy for an additional term or terms. However, petitioner's OR policies provided that a refusal to renew would be without prejudice to any claim originating while the policy was in force. Moreover, petitioner followed the practice of never refusing to renew a policy under such circumstances. With respect to group policies, petitioner was obligated by State law, as quoted above, to provide for certain benefits which extended beyond the policy period in cases where an individual left a covered group or a group policy was terminated. Petitioner also had extended liability during *305 a grace period for a premium payment provided the premium was actually paid during such grace period. To administer benefit claims, develop claim reserves, and determine the proper commencement date of benefit periods, petitioner assigned a loss "incurred date" to each*158 claim made under its A & H policies. The assignment of incurred dates in this manner permitted claims for all reimbursable expenses arising out of the same claim event, i.e., injury or sickness, to be grouped together because the same loss-incurred date was given to all claims made during the benefit period which were attributable to the same cause. Furthermore, the same incurred date was assigned to a recurring surgical procedure or hospitalization if it related to the same cause and was not separated by more than the 90 days, the 180 days, or the 12 months provided by the particular policy involved. The incurred date generally assigned by petitioner to a benefit claim was the date on which the policyholder became liable for the first expense which satisfied the policy's deductible amount for the particular event out of which the claim arose. However, if expenses were still being incurred by an insured with respect to an event when the benefit period expired, it was petitioner's general practice to assign a new incurred date, commence a new benefit period, and impose a new deductible amount. Petitioner was subject to regulation*159 by the Department of Insurance of Wisconsin and a similar department in every other State in which it did business. During the years under consideration each State in which it did business required petitioner to place an actuarially sound value on its liability at yearend under its outstanding medical reimbursement A & H policies for the purpose of determining claim reserves. When making such reserve determinations, petitioner's actuarial judgment was subject to the professional standards of the insurance industry, as well as the regulations of the various States in which it did business. *306 The law regulating claim reserves in Wisconsin appears in the Wisconsin Administrative Code at sec. Ins. 3.17(5). This section provides that the reserve for claim liabilities on all A & H medical reimbursement policies shall be based upon the insurance company's own experience with such policies or other assumptions designed to place a sound value on its liabilities; that the reserve results shall be verified by the development of the company's actual claims over a period of years; and that in computing the reserve the insurer may employ suitable approximations, estimates, groupings, *160 and averages. *161 Using the above guidelines petitioner determined claim reserve amounts for its medical reimbursement policies for each of the years 1972 through 1975. The claim reserve amounts were reported by petitioner on its NAIC statements (Exhibits 9 and 11) to the insurance departments of Wisconsin and the other States in which it did business as well as to respondent. The annual NAIC statements were audited every 3 years for the purpose of determining the solvency of the company and its ability to pay claims. At all times here pertinent, the audits were conducted by Wisconsin's Department of Insurance with the participation of examiners from one or more other States. The results of such audits were filed with and accepted by all the States in which petitioner did business. In determining its medical reimbursement claim reserves during the relevant years, petitioner employed an actuarial method known as the claim lag method. *162 for claims outstanding on a given date are determined by a projection of the company's past experience with the payment of similar claims. The method is based upon, and derives its name from, the estimated lapse of time based upon past experience, i.e., the time lag, between the incurred date assigned to a claim and the actual date or dates upon which the claim will be paid. Under the applicable NAIC instructions, the total amount of petitioner's claim reserves at December 31 of each of the years in issue, was to be determined by computing and multiplying its reserve factor at that date by its reserve base. The reserve base at December 31 was the total amount which had been paid on all claims outstanding at that date. The reserve factor was determined from an analysis of petitioner's past experience with respect to payments made*163 month by month on claims after their incurral dates. In order to quickly estimate its claim reserves at December 31, petitioner had previously adopted and, during the years under consideration, followed the practice of calculating its reserve factor at October 31 and multiplying this factor by its reserve base at December 31. *308 the reserve factor for October 31, which as stated before, was applied to the reserve base at December 31 to determine the aggregate estimated claim reserves as of that date. *164 To estimate the total claims to be ultimately paid, petitioner grouped all claims by the month of incurral. Petitioner then calculated a claim completion factor for each month of incurral through October. The claim completion factor was based on the company's past experience and, in effect, produced a prediction of how many dollars would eventually be paid on claims included in each month of incurral. Petitioner's use of the claim lag method can be illustrated by assuming that as of October 31 of any year, $ 600,000 had been paid on claims incurred (assigned incurral dates) during the month of March of the same year. If petitioner's past experience indicated that 80 percent of claims incurred in March would be paid as of October 31, then the $ 600,000 would represent 80 percent of the total to be ultimately paid on March claims. The estimated ultimate total claim payments on March claims could then be computed as $ 750,000 ($ 600,000 divided by .80). Thus the estimated reserve for March claims as of October 31 would be the difference between the estimate of total March claims to be ultimately paid and the claims paid to date, or $ 150,000 ($ 750,000 minus $ 600,000). With a similar*165 computation for each month of incurral, the estimated aggregate reserves could be determined for October 31 or at any other given date. The estimate of aggregate claim reserves for its medical reimbursement policies as determined in the above manner for December 31 of each of the years in issue was divided by petitioner into an accrued portion and an unaccrued portion using certain percentages based upon actuarial estimates which are acceptable to respondent. For each year, the accrued portion was reported by petitioner to the State regulatory agencies in its NAIC statement under Exhibit 11 (Claim Liability) and the unaccrued portion was reported under Exhibit 9, sec. B (Claim Reserves). On the NAIC form, and in the insurance industry, generally, the accrued portion of the claim reserve represents medical *309 services already rendered to the insured but unpaid by the insurance company as of the valuation date. It includes benefits which are due and payable by the company even though still subject to notification, verification, or contest. The unaccrued portion of a claim reserve represents benefits which are not yet due by the insurance company at the valuation date because*166 the underlying medical services have not been rendered to the insureds even though the claim events, i.e., injuries or sicknesses from which such future benefits will arise, have already occurred. On each of its income tax returns for 1972 through 1975, petitioner claimed deductions for the increases in both the unaccrued and accrued portions of its aggregate reserves as reported on Exhibits 9 and 11, respectively, of its NAIC forms. Respondent allowed the accrued portion as reflected by Exhibit 11. Respondent, however, recomputed the "unaccrued" portion of the claim reserves as shown on Exhibit 9 of petitioner's annual statements for each year and disallowed all of such reserves except the reserves pertaining to certain extended maternity benefits and extended benefits under the disability provisions of the medical expense policies. The following table reflects the benefits excepted from respondent's disallowance:Extended benefits/ loss of time/ Year Deferred group maternity disability 1972 $ 444,292 $ 340,766 1973 504,682 278,317 1974 489,851 184,521 1975 593,516 356,025
The following schedule contains respondent's total net adjustments*167 to petitioner's reserves for the years 1972 through 1975:
INDIVIDUAL GUARANTEED RENEWABLE (GR) | ||||
HOSPITAL/SURGICAL | 1972 | 1973 | 1974 | 1975 |
(Class 6) | ||||
Total reserves (accrued | ||||
and unaccrued) | $ 159,972 | $ 126,061 | $ 436,532 | $ 477,452 |
Percent accrued *169 | 35.3 | 48.55 | 37.04 | 41.25 |
Amount accrued | $ 56,470 | $ 61,203 | $ 161,691 | $ 196,949 |
Adjustments: | ||||
Amount unaccrued | ||||
(total less accrued) | $ 103,502 | $ 64,858 | $ 274,841 | $ 280,503 |
1972 | 1973 | 1974 | 1975 | |
MAJOR MEDICAL | ||||
(Class 7) | ||||
Total reserves (accrued | ||||
and unaccrued) | $ 605,251 | $ 560,531 | $ 683,259 | $ 934,321 |
Percent accrued | 22.9 | 29.27 | 25.27 | 24.89 |
Amount accrued | $ 138,603 | $ 164,067 | $ 172,660 | $ 232,553 |
Adjustments: | ||||
Amount unaccrued | ||||
(total less accrued) | $ 466,648 | $ 396,464 | $ 510,599 | $ 701,768 |
Total adjustments to | ||||
GR claim reserves: | $ 570,150 | $ 461,322 | $ 785,440 | $ 982,271 |
INDIVIDUAL OPTIONAL RENEWABLE (OR) | ||||
HOSPITAL/SURGICAL | 1972 | 1973 | 1974 | 1975 |
(Class G) | ||||
Total reserves (accrued | ||||
and unaccrued) | $ 363,542 | $ 344,832 | $ 413,238 | $ 350,813 |
Percent accrued | 33.4 | 35.71 | 27.47 | 38.95 |
Amount accrued | $ 121,423 | $ 123,140 | $ 113,516 | $ 136,642 |
Adjustments: | ||||
Amount unaccrued | ||||
total less accrued | $ 242,119 | $ 221,692 | $ 299,722 | $ 214,171 |
MAJOR MEDICAL | ||||
(Class H) | ||||
Total reserves (accrued | ||||
and unaccrued) | $ 2,319,359 | $ 2,199,320 | $ 2,762,850 | $ 4,358,904 |
Percent accrued | 29.5 | 33.95 | 31.29 | 31.35 |
Amount accrued | $ 684,211 | $ 746,669 | $ 864,496 | $ 1,366,516 |
Adjustments: | ||||
Amount unaccrued | ||||
(total less accrued) | $ 1,635,148 | $ 1,452,651 | $ 1,898,354 | $ 2,992,388 |
Total adjustments to | ||||
OR claim reserves | $ 1,877,267 | $ 1,674,343 | $ 2,198,076 | $ 3,206,559 |
GROUP POLICIES | 1972 | 1973 | 1974 | 1975 |
Total claim reserves (accrued and | ||||
unaccrued) | $ 5,618,947 | $ 6,404,693 | $ 6,564,466 | $ 8,309,657 |
Percent accrued | 25.2 | 36.65 | 29.25 | 25.86 |
Amount accrued | $ 1,415,975 | $ 2,219,226 | $ 1,920,106 | $ 2,148,877 |
Adjustments: | ||||
Amount unaccrued | ||||
(total less accrued) | $ 4,202,972 | $ 4,185,467 | $ 4,644,360 | $ 6,160,780 |
Less: unaccrued | ||||
exception for extended | ||||
benefits (loss of | ||||
time/disability) | ($ 340,766) | ($ 278,317) | ($ 184,521) | ($ 356,025) |
Total group adjustments: | $ 3,862,206 | $ 3,907,150 | $ 4,459,839 | $ 5,804,755 |
COMBINED TOTAL ADJUSTMENTS | ||||
1972 | 1973 | 1974 | 1975 | |
Individual guaranteed | ||||
renewable (GR) reserves | $ 570,151 | $ 461,322 | $ 785,440 | $ 982,271 |
Individual optionally | ||||
renewable (OR) reserves | $ 1,877,267 | $ 1,674,343 | $ 2,198,076 | $ 3,206,559 |
Group reserves | $ 3,862,206 | $ 3,907,150 | $ 4,459,839 | $ 5,804,755 |
Grand total | $ 6,309,624 | $ 6,042,815 | $ 7,443,355 | $ 9,993,585 |
Less: Prior years' | ||||
adjustments | ($ 6,309,624) | ($ 6,042,815) | ($ 7,443,355) | |
Total net adjustments | $ 6,309,624 | ($ 266,809) | $ 1,400,540 | $ 2,550,230 |
With respect to the claim reserves for its medical reimbursement policies, petitioner maintained for each of the years in dispute schedules known as claim runs or claim runouts for the following 6 years. These schedules were used by petitioner in the preparation of its NAIC forms. 1972 1973 1974 1975 Year 1 74.5% 74.9% 82.8% 71.0% Year 2 85.4 90.1 99.1 84.8 Year 3 91.6 96.9 106.9 90.7 Year 4 95.0 101.3 110.7 92.3 Year 5 97.8 103.6 111.8 93.1 Year 6 99.4 104.4 112.4 93.9
During each of the years under consideration, *170 petitioner maintained and reported on its annual statements a reserve for unearned premiums on its medical expense policies. An unearned premium reserve is maintained by an insurance company in order to reflect the amount of premiums which have been received by the reporting date but which are not yet considered as being earned.
*312 For each of the years 1972 through 1975, petitioner determined its unearned premium reserve for its medical expense policies on the basis of the pro rata lapse of time. Petitioner's method of reserving unearned premiums can be illustrated by assuming that on December 1 of any given year a 1-year premium for a medical expense policy was received. On December 31 of that year, one-twelfth of the premium would be considered as earned and the other eleven-twelfths of the premium would be considered as unearned and would be reflected in the unearned premium reserve.
Respondent does not challenge petitioner's use of the claim lag method for computing its claim reserves including the use of its October 31 reserve factor to compute the claim reserves at December 31. Respondent contends, however, that petitioner overstated its claim reserves and its resulting*171 deductions under
Petitioner contends (1) that its assignment of incurral dates is proper; (2) that the deductions claimed with respect to its reserves are correct; (3) that respondent's determination with respect to the reserves is so arbitrary and unreasonable it does not qualify for the usual presumption of correctness, and, as a result, respondent has the burden of proof, which we treat as a request that the burden of going forward with the evidence be shifted to respondent, with respect to the correct amount of the reserves; and (4) that in the alternative, if petitioner's computation of the reserves is incorrect, petitioner is entitled to spread any adjustment for the year 1972 over the 10-year period provided by section 810(d).
*313 OPINION
For convenience, we will first consider petitioner's contention that respondent's determination with regard to the claim reserves as set forth in the statutory notice is so arbitrary and unreasonable that the determination is not entitled to its usual presumption of correctness and consequently respondent has the burden of going forward with respect to the correct amount of such reserves. In support of this position, petitioner relies upon
Petitioner's reliance in this case upon
When as here, a taxpayer claims a deduction which is disallowed by the Internal Revenue Service, the burden is on the taxpayer to prove to the Tax Court the merit of the deduction. The shifting of that burden can only be caused by the interjection of 'new matter' as provided by Rule 32 of the Rules of Practice of the United States Tax Court. [
*175
Other circuits have reached the same conclusion. See
In view of the foregoing, it is apparent that petitioner in this case has the burden of proof and the burden of going forward with regard to the proper amount of its deduction for claim reserves. This would be true even though we were able to conclude, which we cannot on this record, that under all of the relevant facts respondent's determination was arbitrary and unreasonable.
With respect to this issue, petitioner contends that the deduction of the increases in the unaccrued portions of its reserves, as shown on Exhibit 9 of its NAIC statements are properly allowable under
*315 Respondent first contends that the deductions with respect to unaccrued claims are not allowable because under sections 801, 809, and 810 and the regulations applicable thereto "unpaid losses" and "losses incurred" refer only to
Respondent further contends that the correct amount of petitioner's deductions for losses incurred or reserves therefor cannot be determined for income tax purposes by reference to the accounting requirements of the NAIC.
As a life insurance company, petitioner is taxable under sections 801 through 820 as they existed during the years in issue. These sections comprise a three-phase taxing scheme that first *177 appeared in the Life Insurance Company Income Tax Act of 1959.
(1) Death Benefits, Etc. -- All claims and (2) Increases in Certain Reserves. -- The net increase in reserves which is
The net increase in reserves to be taken into account under
*178 (b) Adjustment for Increase. -- If the sum of the items described in subsection (c) as of the close of the taxable year * * * exceeds the sum of such items as of the beginning of the taxable year, the excess shall be taken into account as a net increase referred to in
*316 (c) Items Taken Into Account. -- The items referred to in [subsections] * * * (b) are as follows:
* * * * (2) The unearned premiums and According to respondent, the proper incurred date for each claim arising under petitioner's policies is the day upon which a covered expense becomes an "existing" liability of petitioner. In his view, this is the day that the medical service or expense underlying the claim is rendered to the insured We are unable to agree with respondent's view of the correct method for assigning incurred dates for the following reasons: *317 (1) The use of respondent's method would eliminate the need for (3) The adoption of respondent's method of assigning incurred dates would also force one to ignore the fact that, as discussed in (6) below, petitioner has established it can from past experience reasonably estimate at the end of any year on an aggregate basis the amount of claims which would be in the situation described in paragraph (2) above and the amount of risk associated with such claims. (4) In order to adopt respondent's method, we would*182 also have to overlook the fact that neither respondent, his experts, nor the experts for petitioner know of any insurance company which uses the method advocated by respondent for the assignment of incurral dates on claims under medical reimbursement policies. In fact, the consensus of all the experts appears to be that it would be impossible for an insurance company to administer such claims with the use of such a method because of the astronomical increase in *318 the number of incurral dates (the date upon which each of the covered medical expenses is paid while the applicable policy is in force). (5) Respondent's contention in this case with respect to incurral dates and the resulting disallowance of deductions for increases in petitioner's reserves for unpaid losses because petitioner's liability is not "in existence" at yearend is inconsistent with respondent's treatment of "losses incurred (whether or not ascertained)" in the regulations issued by respondent under The "losses incurred (whether or not ascertained), during the taxable year" for which a deduction is allowed in The increase in reserves for which a deduction is allowable under In spite of respondent's insistence to the contrary, we are unable to conclude that the estimated losses underlying petitioner's reserves, as well as its increases to such reserves, do not constitute "a reasonable estimate of the amount of the losses * * * which have occurred by the end of*184 the taxable year but which have not been reported or paid," as provided in *319 Respondent, however, contends that under the foregoing sections of the Code and regulations, the phrases "unpaid losses" and "losses incurred" have reference solely to It appears that respondent's position in this case*185 is very similar to that in In Although (6) Finally, we are unable to agree with respondent's method of assigning incurral dates because from the record as a whole we are satisfied that petitioner's computation of the claim reserves by the use of its incurral dates and the claim lag method is consistent with the applicable State law, the NAIC requirements, and, under In support of its claim reserves, petitioner called three expert *187 witnesses. The first was William A. Halvorson of Milliman & Robertson, Inc., consulting actuaries, Milwaukee, Wisconsin. Mr. Halvorson has been a fellow in the Society of Actuaries, the highest designation of actuary in the United States since 1954, and was president of the Society of Actuaries during 1977 and 1978, and at the time of the trial was the president of the American Academy of Actuaries. He has been the consulting actuary for petitioner since 1964. Mr. Halvorson testified that the claim lag method used by petitioner is the most common actuarial method used to determine claim reserves for medical expenses, that petitioner properly employed the method, and that in his opinion, it is the best actuarial method available to reflect an insurance company's true experience with respect to claim payments. In the opinion of Mr. Halvorson, petitioner's procedure for the assignment of incurral dates is an acceptable and correct procedure and its claim reserves, both accrued and unaccrued, as produced with such incurral dates are proper and correct. He testified that in his opinion, any change in petitioner's method of determining claim reserves would result in a similar and offsetting*188 change in its unearned premium reserves. *321 Mr. Halvorson rejected the method of assigning incurred dates espoused by James J. Olsen, one of respondent's expert witnesses, because, according to Halvorson, the method recommended by Olsen contemplated that all policies terminated on the valuation date, and any method which included such a contemplation was improper. Mr. Halvorson also stated that the claim lag method as used by petitioner takes into account the company's actual experience in the past with policy terminations, for nonpayment of premiums, or otherwise. Halvorson testified that in any event, the use of the method recommended by Olsen as explained in his report would result in the allowance of a major portion of the claim reserves which were disallowed by respondent in the statutory notice. The second expert witness called by petitioner was Anthony J. Houghton, of Tillinghast, Nelson & Warren, Inc., consulting actuaries, St. Louis, Missouri. Mr. Houghton is a fellow in the Society of Actuaries and a charter member of the American Society of Actuaries. He is also a fellow in the Conference of Actuaries in Public Practice and several other actuarial organizations. *189 He devotes at least 90 percent of his time to the area of health insurance and reserving methods, both individual and group. Mr. Houghton testified that the most appropriate incurral date for major medical coverage is the date the first medical expense is incurred by the insured which satisfies the deductible amount in the policy. He stated that policy language which requires the expense to be incurred while the policy remains in force is common language in the industry and should not affect or change the commonly accepted methods of assigning incurral dates. Prior to trial, he had surveyed the incurral dating methods used by other insurers in the same line of business as petitioner and found that petitioner's methods in this respect were consistent with the methods commonly used by such companies. He was unable to find any company among those surveyed which used an incurral dating method similar to that proposed by respondent. In his opinion, the method proposed by respondent is unreasonable, not actuarily acceptable, and would lead to improper reserving practices. He *322 was not aware of any insurance company which assigned incurral dates in accordance with respondent's*190 proposed method. He stated that the 1977 NAIC advisory committee report which was referred to and relied upon to some extent by Mr. Olsen, discussed only minimum reserves, did not support Mr. Olsen's position, and had not been formally adopted by the NAIC or by any State. The third expert witness called by petitioner was Bradford S. Gile, a professional actuary employed by the Wisconsin Department of Insurance. Part of his responsibility is to review the reserving practices by insurance companies within the jurisdiction of the department and to determine whether the reserves shown on their NAIC annual statements are proper. If they are determined not to be, it is his responsibility to require the substitution of an examiner's reserve. Mr. Gile testified that the claim lag method is used by the Wisconsin Department of Insurance to verify the sufficiency of reserves subject to its regulations, and that under the applicable State law, the Wisconsin Commissioner of Insurance is empowered to set reserve standards and to adjust reserves if they do not bear an appropriate relationship to the company's obligations under its policies. Mr. Gile also testified that under the reserving standards*191 established by section Ins. 3.17 of the Wisconsin Administrative Code, medical expense claim reserves must be based on the individual company's own experience and other assumptions designed to place a sound value on the underlying claims. Under the applicable State law, the reserves are to be verified by the development of each year's claims over a period of years as set forth in Exhibit O to the NAIC annual statements. He testified that during the years under consideration, petitioner maintained claim runout schedules which were acceptable to his department, and that as an actuary for the State of Wisconsin, he had no disagreement with the incurral dating and the claim development method used by petitioner. Mr. Gile testified that in his opinion the Wisconsin Department of Insurance would not accept claim reserves established in the manner proposed by respondent, and he sharply disagreed with Mr. Olsen's position that reserves *323 are not required for expenses incurred by an insured after a reserve valuation date, unless the policy, by its terms, is continued in force after the valuation date. He stated that his department did require such reserves under such circumstances. *192 He also disagreed with Mr. Olsen's proposed assignment of incurral dates (the dates on which the insured incurs each separate expense). In Mr. Gile's opinion, his department would not permit the use of such a method of assigning incurral dates. He said that under the reserve method proposed by respondent and his expert, there is an implicit assumption that all policies terminate on each valuation date, and that with this assumption, a proper reserve cannot be developed for such policies and that a reasonable rate structure could not be devised to accommodate such an incurral dating method. With respect to the 1977 advisory committee report relied upon by Mr. Olsen, Mr. Gile stated that the report has never been adopted by NAIC, the State of Wisconsin, or to his knowledge by any other State. He stated that he was a member of the NAIC committee to which this advisory report was directed, and that it was his understanding that the report was designed to recommend minimum reserves, but that even in this respect, the report has never been followed. Mr. Gile stated that he was thoroughly familiar with the use of the claim lag method and had carefully reviewed the method as used by petitioner*193 and that, in his opinion, the company's experience with policy terminations for any reason and the effect of policy terminations on the payment of claims is reflected in the statistics used by the claim lag method and thus would be reflected in the reserve which results from the development of the statistics. Mr. Gile explained the relationship between a company's pricing methods and its reserving methods and indicated that there must be a correlation between the two. He explained that pricing in accordance with the Olsen method of assigning incurral dates would result in a rapidly escalating rate structure since medical expenses attributable to losses incurred in prior policy periods, as well as the expenses attributable to the losses incurred in subsequent periods, would both have to be paid out of premiums in the *324 subsequent periods. He said that such a practice would result in an impractical and "nightmarish" rate structure that would lead to difficult adverse selection problems by the company, because as the premium rates rose in later policy years, only high-risk policyholders in claim status would be likely to retain their policies. Mr. Gile testified that from *194 his experience, he knows of no insurance company which has attempted to price policies in this fashion. He also stated that petitioner's policy language that requires the expense to be incurred while the policy is in force is almost universal language and would have no particular bearing on any of his conclusions. We found each of petitioner's experts to be extremely knowledgeable, forthright, and credible, and from their reports and testimony, we are satisfied that petitioner's method of assigning incurral dates to claims and its use of the claim lag method to compute claim reserves are proper and correct. For the same reasons we are also satisfied that petitioner's computations of claim reserves for its medical expense policies at the end of each of the years 1972, 1973, 1974 and 1975 are correct, proper, and in accordance with the NAIC requirements and the laws of Wisconsin. The requirements applicable to all computations entering into the determination of income taxes imposed against life insurance companies are contained in (1) under an accrual method of accounting, or (2) to the extent permitted under regulations prescribed by the Secretary, under a combination of an accrual method of accounting with any other method permitted by this chapter (other than the cash receipts and disbursements method). The above section first appeared in the Life Insurance Company Income Tax Act of 1959 and the following language makes it clear that Congress recognized the importance of the changes made therein: *325 6. * * * * (a) The pertinent language of the report of the Ways and Means Committee of the House is to the same effect. H. Rept. 34, 86th Cong., 1st Sess. (1959), Respondent contends that under The general rules of accrual accounting and the applicable sections*198 of the Code and regulations are silent with regard to the question of the method for determining the reserves under consideration in this case. However, the NAIC form and its accompanying instructions contain detailed specifications as to how the reserves are to be calculated. Under similar circumstances, the Supreme Court has held that the NAIC accounting procedures are to govern. *200 The position taken in In this case the claim runout data developed by petitioner indicates beyond any doubt that its claim payments were consistent with the amounts established in its reserves. It is apparent, therefore, that petitioner during the years under consideration was in substantial compliance with the reserve requirements of NAIC. In view of all of the foregoing, we conclude that petitioner has carried its burden of proving that during each of the years 1972 through 1975, its medical insurance claim reserves were properly computed and the deductions claimed with respect thereto are allowable. Decision will be entered under Rule 155.
1. All section references are to the Internal Revenue Code of 1954 as amended during the years in issue, unless otherwise indicated. All Rule references are to the Tax Court Rules of Practice and Procedure, unless otherwise provided.↩
2. The term "insured" as used herein means the policyholder under an individual policy, the participant or member under a group policy, and all covered dependents of such persons.↩
3. The group policies included both hospital/surgical and major medical benefits, but the benefits were not separated into different classes of business.↩
4. No question has been raised as to whether or not this type of policy qualifies as a noncancelable health and accident insurance contract under sec. 801(b) or (e).↩
5. Sec. Ins. 3.17(5) of the Wis. Admin. Code provides in part as follows:
(5) Claim Liability Reserves, Individual and Franchise. Claim liability reserves to represent the value of amounts not yet due on claims are required for all policies issued subject to subsection 201.04(4) of Ins. 6.70, section 600.03 (34m) (d), or 632.94, Wis. Stats.
(a) The minimum reserve for claim liabilities shall be computed employing the following assumptions:
* * * *
a. Disability due to accident and sickness: * * *
b. All other benefits: The reserve shall be based on the individual company's experience or other assumptions designed to place a sound value on the liabilities. The results shall be verified by the development of each year's claims over a period of years.
(b) Insurers may employ suitable approximations and estimates, including but not limited to groupings and averages, in computing claim liability reserves.
(c) For policies with an elimination period, the duration of disablement should be considered as dating from the time that benefits would have begun to accrue had there been no elimination period.
(d) A new disability connected directly or indirectly with a previous disability which had a duration of at least one year and terminated within 6 months of the new disability should be considered a continuation of the previous disability.↩
6. The method is referred to by respondent as the claim completion method. The same method is sometimes referred to in the industry as the claim development method, or lag studies method.↩
7. Respondent has made no objection to this practice.↩
1. Derived from percentages used by petitioner in dividing the total A & H medical expense reserves into the accrued (Exhibit 11) and unaccrued (Exhibit 9) portions of the annual statement. Respondent used these same percentages in connection with his determination.↩
2. The unaccrued exception for deferred maternity benefits is not included in the totals.↩
8. Petitioner was not required by NAIC to maintain the claim runout schedules beyond 3 years.↩
9. Pub. L. 86-69, 86th Cong., 1st Sess. (1959), 73 Stat. 112.↩
10. During the years under consideration, sec. 801(c) read as follows:
SEC. 801(c). Total Reserves Defined. -- For purposes of subsection (a), the term "total reserves" means -- (1) life insurance reserves, (2) unearned premiums, and unpaid losses (whether or not ascertained), not included in life insurance reserves, and (3) all other insurance reserves required by law.↩
11. As noted by petitioner, acceptance of respondent's theory with regard to reserves for medical expense policies would require one to also accept the reasoning that a life insurance company cannot establish a reserve for a life policy until the death of the insured because it is not known until that time that the policy will not lapse prior to the insured's death for nonpayment of premiums.↩
12. Tax scholars have interpreted
13. Our disposition of this issue also disposes of the issue with respect to the spread forward under sec. 810(d).↩
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