§ 8093.
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§ 8093. Denial of claims; written explanation
(a)If a claim under a long-term care insurance contract is denied, the issuer shall, within 60 days of the date of a written request by the policyholder or certificate holder, or a representative thereof:
(1)provide a written explanation of the reasons for the denial; and
(2)make available all information directly related to the denial.
(b)After completion of all internal appeals, the policyholder or certificate holder may appeal the insurer’s benefit trigger determination to an independent review organization designated by the Commissioner, upon payment of a filing fee of no more than $15.00. The filing fee may be waived or reduced upon a finding by the Commissioner that the financial circumstances of the insured warrant a waiver or reduction. All other costs of the independent review shall be paid by the insurer. (Added 2003, No. 124 (Adj. Sess.), § 2, eff. Jan. 1, 2005; amended 2009, No. 137 (Adj. Sess.), § 28.)