NRS 695A.188 Approval or denial of claim; payment of claims and interest; request for additional information; payment of claim; award of costs and attorney’s fees; compliance with requirements; imposition of administrative fine or suspension or revocation of certificate of authority for failure to comply; report of compliance by society.

920 words·~4 min read·/nv/chapter-695a-fraternal-benefit-societies/695a-188·

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

1. Except as otherwise provided in subsection 3 and NRS 439B.754 , a society shall approve or deny a claim relating to a certificate of health insurance and, if the society:

(a)Approves the claim, pay the claim within:

(1)Twenty-one days after the society receives the claim, if the claim is submitted electronically; or

(2)Thirty days after the society receives the claim, if the claim is not submitted electronically.

(b)Denies the claim, notify the claimant in writing of the denial within 21 days after the society receives the claim, if the claim is submitted electronically, or 30 days after the society receives the claim, if the claim is not submitted electronically. The notice must include, without limitation:

(1)All reasons for denying the claim, including, without limitation, the specific facts and provisions of the certificate relied upon by the society as a basis to deny the claim;

(2)The criteria by which the society determines whether to approve or deny the claim and a description of the manner in which the society applied those criteria to the claim; and

(3)A summary of any applicable process established pursuant to NRS 687B.820 for challenging the denial of the claim.

2. Except as otherwise provided in this section, if the approved claim is not paid within the period specified by subsection 1, the society shall pay interest on the claim at the rate of 10 percent per annum. The interest must be calculated from the date on which payment of the claim is due pursuant to subsection 1 until the claim is paid.

3. If the society requires additional information to determine whether to approve or deny the claim, it shall notify the claimant of its request for the additional information within 20 working days after it receives the claim. The society shall notify the claimant of all the specific reasons for the delay in approving or denying the claim. The society shall approve or deny the claim and, if the society:

(a)Approves the claim, pay the claim within:

(1)Twenty-one days after receiving the additional information, if the information is submitted electronically; or

(2)Thirty days after receiving the additional information, if the information is not submitted electronically.

(b)Denies the claim, provide notice of the denial in the manner prescribed in paragraph

(b)of subsection 1 within 21 days after receiving the additional information, if the information is submitted electronically, or 30 days after receiving the information, if the information is not submitted electronically.

4. If a claim approved pursuant to subsection 3 is not paid within the period specified in that subsection, the society shall pay interest on the claim in the manner prescribed in subsection 2.

5. A society shall not:

(a)Deny a claim without a reasonable basis for the denial.

(b)Request a claimant to resubmit information that the claimant has already provided to the society, unless the society provides a legitimate reason for the request and the purpose of the request is not to delay the payment of the claim, harass the claimant or discourage the filing of claims.

6. A society shall not pay only part of a claim that has been approved and is fully payable.

7. A court shall award costs and reasonable attorney’s fees to the prevailing party in an action brought pursuant to this section.

8. The payment of interest provided for in this section for the late payment of an approved claim may be waived only if the payment was delayed because of an act of God or another cause beyond the control of the society.

9. The Commissioner may require a society to provide evidence which demonstrates that the society has substantially complied with the requirements set forth in this section, including, without limitation, payment within the time periods specified by this section of at least 95 percent of approved claims or at least 90 percent of the total dollar amount for approved claims.

10. If the Commissioner determines that a society is not in substantial compliance with the requirements set forth in this section or has failed to approve or deny a claim or pay an approved claim within 60 working days after receiving the claim, the Commissioner may require the society to pay an administrative fine in an amount to be determined by the Commissioner. Upon a second or subsequent determination that a society is not in substantial compliance with the requirements set forth in this section or has failed to approve or deny a claim or pay an approved claim within 60 working days after receiving the claim, the Commissioner may suspend or revoke the certificate of authority of the society.

11. On or before February 1 of each year, a society shall submit to the Commissioner a report concerning the compliance of the society with the requirements of this section during the immediately preceding calendar year. The report must include, without limitation:

(a)The number of claims for which the society failed to comply with the requirements of subsections 1 and 3 during the immediately preceding calendar year; and

(b)The total amount of interest paid by the society pursuant to subsections 2 and 4 during the immediately preceding calendar year.