02-031-420 Me. Code R. § 9

Current through 2024-46, November 13, 2024

Section 031-420-9 - Payment of Claims

Upon receipt of a notice of claim for benefits under a policy or certificate of long-term care insurance delivered or issued for delivery in this State, and after the insurer has sent the written statement required by 24-A M.R.S.A. §5083(1) and received the information identified in 24-A M.R.S.A. §5083(2), a long-term care insurer shall pay or deny the claim within 30 days, except as otherwise permitted by this section. If the insurer is unable to decide the claim because more information is needed, it may request necessary additional documentation, consistent with Subsection A, with sufficient detail to permitthe insured to understand and respond. The written request must be provided by the insurer within 10 business days after receipt of the notice of claim. For purposes of this section, "insured" includes the insured's authorized representative.

A.Documentation

The documentation an insurer may require of an insured following the submission of a claim for benefits under a policy or certificate of long-term care insurance is as follows:

1. A brief statement by or on behalf of the insured describing the basis of the claim for benefits;

2. A signed release permitting the insurer to obtain personal health information about the insured pursuant to the federal Health Insurance Portability and Accountability Act of 1996;

3. A statement from the insured's physician, including the appropriate diagnosis and a treatment and care plan for the insured;

4. A statement from the long-term care provider rendering services to the insured, including an itemized bill for services, the provider's license number, and any daily nursing notes;

5. A copy of any power of attorney executed by the insured; and

6. Other information that the insurer determines is reasonably necessary to evaluate before making a determination on the claim and is not readily available from sources other than the insured.

B.Burden on Insurer

Except for information solely in the possession of the insured, the burden is on the insurer to obtain any information other than that described in Paragraphs (A)(1) to (A)(6) that is reasonably necessary to pay or continue paying the claim.

C.Delay or Denial of Claim

If the insurer denies a claim in whole or part, the insurer shall promptly issue a written notice to the insured explaining the specific reason or reasons for the denial. If the insurer cannot pay the claim within 30 days because it does not have sufficient information to make a decision, the insurer shall decide the claim and notify the insured in accordance with the following requirements.

1. An insurer may not extend the time for resolution of a claim beyond 30 days after receipt of documentation and information related to a technical issue. The insurer may not extend the time period beyond 30 days for documentation that the insurer already possesses.

2. An insurer may not extend the time for resolution of a claim beyond 30 days after receipt of all documentation and information initially requested from the insured unless the insurer determines, as a result of its review of that information, that the insurer cannot reasonably decide the claim without additional information relating to a substantive issue.

a. The insurer may not delay the resolution of the claim any longer than is reasonably necessary and must act expeditiously to obtain all necessary information.

b. If the resolution of the claim is being delayed because a source other than the insured is failing to provide necessary information, the insurer shall notify the insured of the reason for the delay and the nature of the missing information, unless such notice might prejudice the insurer's investigation of suspected fraud or other misconduct.

D.Ongoing Claim

Except for information solely in the possession of the insured, if, during the course of an ongoing claim for benefits paid on a monthly or recurring basis, the insurer identifies additional documentation that is reasonably necessary to verify that the insured remains entitled to benefits under the policy or certificate of long-term care insurance, the burden is on the insurer to obtain that information.

E.Appeals of Claims Denials

An insured who receives a claims denial has the right to internal appeal. In addition, if the claims denial is eligible for external review, the insured has the right to request an external review under Section 11 of this rule. The written notice to the insured of the claims denial as required by Subsection C must include: a statement informing the insured of the insured's right to internal appeal, and of the right to external review in the case of a claims denial eligible for external review; a statement of the insured's right to seek assistance or file a complaint with the Superintendent; and contact information for the Bureau, including its toll-free telephone number and Internet address.

(Drafting Note: Although this section does not apply to contracts issued or issued for delivery in other states even if the insured becomes a resident of this state, insurers are encouraged to voluntarily adopt these standards for insureds who obtain long-term care services in this state. Nothing in this rule prohibits insurers from voluntarily complying with this section.)

02-031 C.M.R. ch. 420, § 9