Section 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.

2008 Acts, ch 1175, §10, 18