514G.109 - BENEFIT TRIGGER DETERMINATIONS -- NOTICE -- APPEALS.

        514G.109  BENEFIT TRIGGER DETERMINATIONS -- NOTICE --      APPEALS.         1.  Notice.  When a long-term care insurer determines that the      benefit trigger in an insured's long-term care insurance policy has      not been met, the insurer shall provide a clear, written notice to      the insured of all of the following:         a.  The reason that the insurer determined that the insured's      benefit trigger has not been met.         b.  The insurer's internal appeal process provided under the      insured's long-term care insurance policy.         c.  The insured's right, after exhaustion of the insurer's      internal appeal process, to have the benefit trigger determination      reviewed under the independent review process set forth in section      514G.110.         2.  Internal appeal.         a.  An insured may request an internal appeal of a benefit      trigger determination by sending a written request to the insurer,      along with any additional supporting information, within sixty days      after the insured receives the notice described in subsection 1.  The      internal appeal shall be considered by an individual or group of      individuals designated by the insurer, provided that the individual      or individuals making the internal appeal decision shall not be the      same individual or individuals who made the initial benefit trigger      determination.  All internal appeals shall be completed and written      notice of the internal appeal decision sent to the insured within      sixty days of the insurer's receipt of all necessary information upon      which a final determination can be made.         b.  If the determination that the benefit trigger was not met      is upheld upon internal appeal, the notice of the appeal decision      shall describe additional internal appeal rights that are offered by      the insurer, if any.  Nothing in this paragraph shall require an      insurer to offer any internal appeal rights other than those      described in paragraph "a".         c.  If the determination that the benefit trigger was not met      is upheld after the internal appeal process has been exhausted and      there is no new information not previously provided to the insurer      for consideration, the insurer shall provide the insured with a      written description of the insured's right to request an independent      review of the benefit trigger determination.         3.  Receipt of notice.  Notices required by this section shall      be deemed received within five days after the date of mailing.  
         Section History: Recent Form
         2008 Acts, ch 1175, §10, 18         Referred to in § 514G.110