CHAPTER Ins 3900 OTHER INSURANCES
Statutory Authority:
RSA 400-A:15; RSA 415-A:6, II.
PART Ins 3901
GROUP DISABILITY INSURANCE CLAIM PROCESSING STANDARDS
Ins
3901.01 Purpose and Scope. In accordance with RSA 415-A and the U.S. Department
of Labor Benefit Claims Procedure Regulation, 29 CFR 2560.503, this section
establishes the minimum requirements for carriers pertaining to the processing
of claims for disability benefits by
participants and claimants. These
requirements shall apply to every group policy provided by the carrier that
contains disability benefits.
Source.
#8020, eff 3-1-04; ss by #10122, eff 5-1-12
Ins
3901.02 Definitions.
(a) "Adverse benefit determination"
means a denial, reduction, or termination of, or a failure to provide or make
payment (in whole or in part) for, a benefit, including any such denial,
reduction, termination, or failure to provide or make payment that is based on
a determination of a participant's or claimant's eligibility to participate in
a plan, and including a denial, reduction, or termination of, or a failure to
provide or make payment (in whole or in part) for, a benefit resulting from the
application of any utilization review, as well as a failure to cover an item or
service for which benefits are otherwise provided because it is determined to
be experimental or investigational or not medically necessary or appropriate.
(b) "Health care professional" means a
physician or other health care provider who is licensed, accredited, or
certified to perform specified health services consistent with state law.
(c) "Relevant to a claimant's claim"
means, when used in reference to a document, record or other information, that
the document, record or other information:
(1) Was relied
upon in making the benefit determination;
(2) Was
submitted, considered, or generated in the course of making the benefit
determination, without regard to whether such document, record, or other
information was relied upon in making the benefit determination;
(3)
Demonstrates compliance with the administrative processes and safeguards
required in making the benefit determination; or
(4) Constitutes
a statement of policy or guidance with respect to the carrier's policy
concerning the denied treatment option or benefit for the claimant's diagnosis,
without regard to whether such advice or statement was relied upon in making
the benefit determination.
Source.
#8020, eff 3-1-04; ss by #10122, eff 5-1-12
Ins
3901.03 Claims Procedures.
(a) Health carriers that offer disability
benefits shall establish and maintain reasonable procedures governing the filing
of benefit claims, notification of benefit determinations, and appeal of
adverse benefit determinations, hereinafter collectively referred to as claims
procedures. The claims procedures shall
be deemed by the department to be reasonable only if:
(1) They
contain a description of all procedures, including any procedures for obtaining
prior approval as a prerequisite for obtaining a benefit, such as
preauthorization procedures or utilization review procedures and the applicable
time frames as part of a summary plan description;
(2) They do not
contain any provision, and are not administered in a way, that unduly inhibits
or hampers the initiation or processing of claims for benefits. A provision or practice that requires payment
of a fee or costs as a condition to making a claim or to appealing an adverse
benefit determination would be considered by the department to unduly inhibit
the initiation and processing of claims for benefits, as would the denial of a
claim for failure to obtain a prior approval under circumstances that would
make obtaining such prior approval impossible or where application of the prior
approval process could seriously jeopardize the life or health of the claimant;
(3) They do not
preclude an authorized representative of a claimant from acting on behalf of
such claimant in pursuing a benefit claim or appeal of an adverse benefit
determination. Nevertheless, a plan may establish reasonable procedures for
determining whether an individual has been authorized to act on behalf of a
claimant; and
(4) They
contain administrative processes and safeguards designed to ensure and to
verify that benefit claim determinations are made in accordance with governing
policy documents and that, where appropriate, the provisions in the policy have
been applied consistently with respect to similarly situated claimants.
(b) Appeal of adverse benefit
determinations. The claims procedures of
group disability coverage for appealing adverse benefit determinations shall be
deemed by the department to be reasonable only if:
(1) They do not
contain any provision, and are not administered in a way, that requires a
claimant to file more than two appeals of an adverse benefit determination
prior to bringing a civil action;
(2) To the extent
that a carrier offers voluntary levels of appeal, including voluntary
arbitration or any other form of dispute resolution, the procedures provide
that:
a. The carrier
waives any right to assert that a claimant has failed to exhaust administrative
remedies because the claimant did not elect to submit a benefit dispute to any
such voluntary level of appeal provided by the carrier;
b. The carrier
agrees that any statute of limitations or other defense based on timeliness is tolled
during the time that any such voluntary appeal is pending;
c. The claims
procedures provide that a claimant may elect to submit a benefit dispute to
such voluntary level of appeal only after exhaustion of the appeals permitted
by this rule;
d. The carrier
provides to any claimant, upon request, sufficient information relating to the
voluntary level of appeal to enable the claimant to make an informed judgment
about whether to submit a benefit dispute to the voluntary level of appeal,
including a statement that the decision of a claimant as to whether or not to
submit a benefit dispute to the voluntary level of appeal will have no effect
on the claimant's rights to any other benefits under the plan and information
about the applicable rules, the claimant's right to representation, the process
for selecting the decision maker, and the circumstances, if any, that may
affect the impartiality of the decision maker, such as any financial or
personal interests in the result or any past or present relationship with any
party to the review process; and
e. No fees or
costs are imposed on the claimant as part of the voluntary level of appeal.
(3) The claims
procedures do not contain any provision for the mandatory arbitration of
adverse benefit determinations, except to the extent that the plan or
procedures provide that:
a. The
arbitration is conducted as one of the two appeals referenced in paragraph
(b)(1) of this section; and
b. The claimant
is not precluded from challenging the decision under any applicable law.
(c) Notification of benefit determination. The claims procedures of group disability
coverage for notifying a claimant of a benefit
determination shall be deemed reasonable by the department only if:
(1) Timing of
notification.
a. When a claim
is wholly or partially denied, the carrier's procedures require it to notify
the claimant of the carrier's adverse benefit determination within a reasonable
period of time, but not later than 45 days after the carrier's receipt of the
claim. This period may be extended for
up to 30 days, provided that the carrier both determines that such an extension
is necessary due to matters beyond its control and notifies the claimant, prior
to the expiration of the initial 45-day period, of the circumstances requiring
the extension of time and the date by which the carrier expects to render a
decision. If, prior to the end of the
first 30-day extension period, the carrier determines that, due to matters
beyond the control of the carrier, a decision cannot be rendered within that
extension period, the period for making the determination may be extended for
up to an additional 30 days, provided that the carrier notifies the claimant,
prior to the expiration of the first 30-day extension period, of the circumstances
requiring the extension and the date as of which the carrier expects to render
a decision. In the case of any
extension, the notice of extension shall specifically explain the standards on
which entitlement to a benefit is based, the unresolved issues that prevent a
decision on the claim, and the additional information needed to resolve those
issues, and the claimant shall be afforded at least 45 days within which to
provide the specified information; and
b. In
calculating time periods for benefit determinations, the period of time within
which a benefit determination is required to be made shall begin at the time a
claim is filed in accordance with the reasonable procedures of a carrier,
without regard to whether all the information necessary to make a benefit
determination accompanies the filing. In
the event that a period of time is extended due to a claimant's failure to
submit information necessary to decide a claim, the period for making the
benefit determination shall be tolled from the date on which the notification
of the extension is sent to the claimant until the date on which the claimant
responds to the request for additional information.
(2) Contents of
notification. The carrier shall provide
a claimant with written or, if requested by the claimant, electronic
notification of any adverse benefit determination. The notification shall set forth, in a manner
calculated to be understood by the claimant:
a. The specific
reason or reasons for the adverse determination;
b. Reference to
the specific policy provisions on which the determination is based;
c. A
description of any additional material or information necessary for the
claimant to perfect the claim and an explanation of why such material or
information is necessary;
d. A
description of the carrier's review procedures and the time limits applicable
to such procedures, including a statement of the claimant's right to bring a
civil action following an adverse benefit determination on review;
e. If an
internal rule, guideline, protocol, or other similar criterion was relied upon
in making the adverse determination, the carrier shall either provide a copy of
the specific rule, guideline, protocol, or other similar criterion, or explain
when the rule, guideline, protocol, or other similar criterion that was relied
upon in making the adverse determination
will be provided; and
f. If the
adverse benefit determination is based on a medical necessity or experimental
treatment or similar exclusion or limit, the carrier shall either provide an
explanation of the scientific or clinical judgment for the determination,
applying the terms of the plan to the claimant's medical circumstances, or
state that such explanation will be provided free of charge upon request.
(d) Appeal of adverse benefit
determinations. Every carrier that
offers group disability insurance shall establish and maintain a procedure by
which a claimant shall have a reasonable opportunity to appeal an adverse
benefit determination to an appropriate named fiduciary of the carrier, and
under which there will be a full and fair review of the claim and the adverse
benefit determination. The claims
procedures of a group disability policy will not be deemed by the department to
provide a claimant with a reasonable opportunity for a full and fair review of
a claim and adverse benefit determination unless the claims procedures:
(1) Provide a
claimant with at least 180 days following receipt of a notification of an
adverse benefit determination within which to appeal the determination;
(2) Provide for
a review that does not afford deference to the initial adverse benefit
determination and that is conducted by an appropriate named fiduciary of the
carrier who is neither the individual who made the adverse benefit determination
that is the subject of the appeal, nor the subordinate of such individual;
(3) Provide
that, in deciding an appeal of any adverse benefit determination that is based
in whole or in part on a medical judgment, including determinations with regard
to whether a particular treatment, drug, or other item is experimental,
investigational, or not medically necessary or appropriate, the appropriate
named fiduciary shall consult with a health care professional who has
appropriate training and experience in the field of medicine involved in the
medical judgment;
(4) Provide for
the identification of medical or vocational experts whose advice was obtained
on behalf of the carrier in connection with a claimant's adverse benefit
determination, without regard to whether the advice was relied upon in making
the benefit determination;
(5) Provide
that the health care professional engaged for purposes of a consultation shall
be an individual who is neither an individual who was consulted in connection
with the adverse benefit determination that is the subject of the appeal, nor
the subordinate of any such individual;
(6) Provide
claimants with the opportunity to submit written comments, documents, records,
and other information relating to the claim for benefits;
(7) Provide
that a claimant shall be provided, upon request and free of charge, reasonable
access to, and copies of, all documents, records and other information relevant
to the claimant's claim for benefits to include specific information relating
to any denial of benefits; and
(8) Provide for
a review that takes into account all comments, documents, records and other
information submitted by the claimant relating to the claim, without regard to
whether such information was submitted or considered in the initial benefit
determination.
(e) Timing of notification of benefit
determination on review.
(1) The carrier
shall notify a claimant of the
outcome of the review conducted under Ins 3901.03(d) within a reasonable period
of time, but not later than 45 days after receipt of the claimant's request for
review by the carrier, unless the carrier determines that special circumstances
(such as the need to hold a hearing, if the carrier's procedures provide for a
hearing) require an extension of time for processing the claim. If the carrier determines that an extension
of time for processing is required, written notice of the extension shall be
furnished to the claimant prior to the termination of the initial 45-day
period. In no event shall such extension
exceed a period of 45 days from the end of the initial period. The extension notice shall indicate the
special circumstances requiring an extension of time and the date by which the
carrier expects to render the determination on review; and
(2) Calculating
time periods. The period of time within
which a benefit determination on review is required to be made shall begin at
the time an appeal is filed in accordance with the procedures the carrier has
established pursuant to Ins 3901.03(a), without regard to whether all the
information necessary to make a benefit determination on review accompanies the
filing. In the event that a period of time is extended due to a claimant's
failure to submit information necessary to decide a claim, the period for
making the benefit determination on review shall be tolled from the date on
which the notification of the extension is sent to the claimant until the date
on which the claimant responds to the request for additional information.
(f) Manner and content of notification of benefit
determination on review. The carrier
shall provide a claimant with written or, if requested by the claimant,
electronic notification of its benefit determination on review. The notification shall set forth, in a manner
calculated to be understood by the claimant:
(1) The
specific reason or reasons for the adverse determination;
(2) Reference
to the specific policy provisions on which the benefit determination is based;
(3) A statement
that the claimant is entitled to receive, upon request and free of charge,
reasonable access to, and copies of, all documents, records, and other
information relevant to the claimant's claim for benefits; and
(4) A statement
describing any voluntary appeal procedures offered by the plan and the
claimant's right to obtain the information about such procedures and a
statement of the claimant's right to bring a legal action.
(5) If an
internal rule, guideline, protocol, or other similar criterion was relied upon
in making the adverse determination, the carrier shall provide the claimant
with either the specific rule, guideline, protocol, or other similar criterion;
or a statement that such rule, guideline, protocol, or other similar criterion
was relied upon in making the adverse determination and shall agree to provide
a copy of the rule, guideline, protocol, or other similar criterion free of
charge to the claimant upon request;
(6) If the
adverse benefit determination is based on a medical necessity or experimental
treatment or similar exclusion or limit, the carrier shall provide either an
explanation of the scientific or clinical judgment for the determination,
applying the terms of the plan to the claimant's medical circumstances, or a
statement that such explanation will be provided free of charge upon request;
and
(7) The carrier
shall include in the notice of adverse benefit determination the statement
"You and your plan may have other voluntary alternative dispute resolution
options, such as mediation. One way to find out what may be available is to
contact your local
Source.
#8020, eff 3-1-04; ss by #10122, eff 5-1-12
Ins
3901.04 Failure to Establish and
Follow Reasonable Claims Procedures.
In the case of the failure of a carrier to establish or follow its
claims and appeals procedures, a claimant shall be deemed by the department to
have exhausted the administrative remedies available under the plan and shall
be entitled to pursue any available legal remedies on the basis that the
carrier has failed to provide a reasonable claims procedure that would yield a
decision on the merits of the claim.
Source.
#8020, eff 3-1-04; ss by #10122, eff 5-1-12
Ins
3901.05 Effective Date. This section shall apply to claims filed
under a plan on or after March 1, 2004.
Source.
#8020, eff 3-1-04; ss by #10122, eff 5-1-12
PART Ins 3902 INDIVIDUAL SUPPLEMENTAL UNEMPLOYMENT
INSURANCE
Statutory Authority: RSA 400-A:15
Ins
3902.01 Purpose. The purpose of this part is to permit the sale
of individual supplementary insurance against the loss of income due to the
involuntary loss of employment and to establish standards governing such
coverage.
Source.
#10863, eff 8-1-15
Ins
3902.02 Scope. This part shall apply to all licensed
insurers authorized to insure casualty risks.
Source.
#10863, eff 8-1-15
Ins
3902.03 Definitions.
(a) “Individual supplemental unemployment insurance”
means individual insurance that provides supplemental benefits, paid directly
to an insured, for protection against the loss of income due to the involuntary
loss of employment.
(b) “Loss of income” means loss of income as the
result of any loss of employment resulting in qualification for unemployment benefits.
(c) “Involuntary
loss of employment” means any loss of employment that qualifies an individual
for unemployment benefits whether or not the loss of employment is considered
involuntary or voluntary as part of the relevant unemployment statutory scheme.
(d) “Unemployment benefits” means the cash benefits paid in accordance with
state unemployment benefit law, Chapter 282-A or any federal unemployment cash
benefits that are administered by the state.
Source.
#10863, eff 8-1-15
Ins
3902.04
Benefits.
(a) Benefits
shall be paid weekly for any involuntary loss of employment, so long as:
(1)
The insured has been approved to receive unemployment benefits; and
(2)
Any waiting period or exclusionary period has elapsed.
(b) The maximum weekly unemployment benefit
payable under a supplemental unemployment insurance policy shall be 50 percent
of weekly wages minus the amount of maximum weekly unemployment benefits at the
time of application for coverage.
(c) For purposes of determining the maximum
weekly benefit payable to the insured under (b) above, weekly wages shall be
the lesser of:
(1)
The weekly wages reported by the insured to the insurer at the time of
initial application, or any subsequent agreed upon increase in equivalent
weekly wages and corresponding increased limits; or
(2)
The insured’s weekly wages as determined by state unemployment
compensation records.
Source.
#10863, eff 8-1-15
Ins
3902.05 Exclusionary Periods.
(a) A policy of individual supplemental
unemployment insurance shall not provide for more than a 6 month exclusionary
period, commencing with the initial policy’s effective date.
(b) If the insured begins a period of involuntary
unemployment during an exclusionary period, the policy shall be terminated and
the insurer shall provide a full refund of premiums paid.
(c) If the insured receives advance oral, written
or other notice of impending unemployment during an exclusionary period and
thereafter begins a period of involuntary unemployment at the same job during the
initial policy period that is directly related to that notice, the policy shall
be terminated and the insurer shall provide a full refund of premium paid.
Source.
#10863, eff 8-1-15
Ins
3902.06 Mandatory Disclosures. The insurer shall disclose the following
information to the insured at the time of the issuance of coverage:
(a) The premium for the initial term of the
insurance coverage;
(b) The term of the insurance coverage;
(c) The number of weekly payments payable to the insured under the
policy, and any limitations on the amount of such payments;
(d) A detailed description how any waiting
period, exclusionary period or elimination period affects benefits payable under the policy; and
(e) The specific requirements that shall be met
if the insured wishes to cancel the
policy.
Source.
#10863, eff 8-1-15
Ins
3902.07 Mandatory Minimum Policy
Provisions.
(a) All supplemental insurance policies shall
contain the following provisions:
(1)
A provision stating that the policy shall conform and operate
consistently with the applicable federal and state laws and rules concerning
unemployment insurance, including any amendments to those laws and rules taking
effect during the term of the policy;
(2)
A provision that gives the insured the right to cancel the policy within
30 days of the insured’s receipt of the policy, with full premium refund, and
at no cost to the insured;
(3)
A provision that terminates the policy, with a full refund of premiums
paid, at no cost to the insured, if the insured becomes unemployed during any
exclusionary period or receives advance oral, written or other notice of
impending unemployment during the exclusionary period, and thereafter begins a
period of involuntary unemployment in the same job during the initial period
that is directly related to the notice; and
(4)
A provision that gives the insured the right to cancel the policy at any
time after 30 days, with a refund of unearned premium.
(b) Supplemental unemployment insurance shall be
subject to all laws and rules governing liability insurance sold under
authority of RSA 401:1,V, including, but not limited to, the cancellation and
nonrenewal provisions for liability insurance under RSA 417-B except as
provided above.
Source.
#10863, eff 8-1-15
Ins
3902.08 Repayment of Benefits. No
insurer shall seek repayment of benefits paid under a supplemental unemployment
policy based upon a reversal of a state decision with respect to eligibility
for unemployment benefits unless:
(a) The state department of employment security
has made a finding of fault in accordance with its administrative rules; or
(b) The insured has been found to have made a
material misrepresentation in the application for coverage that led to approval
of the application, where an accurate representation would have resulted in a
denial of the application.
Source.
#10863, eff 8-1-15
Ins
3902.09 Penalties. Any insurer who shall
knowingly violate any provision of this part shall be subject to the provisions
of RSA 400-A:15, III.
Source.
#10863, eff 8-1-15
APPENDIX
|
Rule |
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|
|
|
|
Ins 3901.01 |
RSA 415-A:6, II and 29 CFR 2560.503 |
|
Ins 3901.02 |
RSA 415-A:6, II and 29 CFR 2560.503 |
|
Ins 3901.03 |
RSA 415-A:6, II and 29 CFR 2560.503 |
|
Ins 3901.04 |
RSA 415-A:6, II and 29 CFR 2560.503 |
|
Ins 3901.05 |
RSA 415-A:6, II and 29 CFR 2560.503 |
|
Ins 3902.01 |
RSA 401:1-a, II |
|
Ins 3902.02 |
RSA 401:1-a, II |
|
Ins 3902.03 |
RSA 401:1-a, II |
|
Ins 3902.04 |
RSA 401:1-a, II |
|
Ins 3902.05 |
RSA 401:1-a, II |
|
Ins 3902.06 |
RSA 401:1-a, II |
|
Ins 3902.07 |
RSA 401:1-a, II; RSA 401:1, V |
|
Ins 3902.08 |
RSA 401:1-a, II |
|
Ins 3902.09 |
RSA 401:1-a, II; RSA 400-A:15, III |