Section 3.55. Benefit appeals under long-term care policies, life insurance-long-term care coverage and Medicare replacement or supplement policies.

 

(1)   Purpose. This section implements and interprets s. 632.84 , Stats., for the purpose of establishing minimum requirements for the internal procedure for benefit appeals that insurers shall provide in long-term care policies, life insurance-long-term care coverage and Medicare replacement or supplement policies. This section also facilitates the review by the commissioner of these policy forms.

(2)   Scope. This section applies to individual and group nursing home insurance policies and Medicare replacement or supplement policies issued or renewed on or after August 1, 1988, and to long-term care policies and life insurance-long-term care coverage issued or renewed on and after June 1, 1991, except for policies or coverage exempt under s. Ins 3.455 (2) (b) . This section does not apply to a health maintenance organization, limited service health organization or preferred provider plan, as those are defined in s. 609.01 , Stats.

(3)   Definitions. In this section:

(a) "Benefit appeal" means a request for further consideration of actions involving the denial of a benefit.

(b) "Denial of a benefit" means any denial of a claim, the application of a limitation or exclusion provision, and any refusal to continue coverage.

(c) "Internal procedure" means the insurer's written procedure for handling benefit appeals.

(cg) "Life insurance-long-term care coverage" has the meaning provided under s. Ins 3.46 (3) (j) .

(cm) "Long-term care policy" has the meaning provided under s. Ins 3.46 (3) (k) .

(d) "Medicare replacement policy" has the meaning given in s. 600.03 (28p) , Stats.

(e) "Medicare supplement policy" has the meaning given in s. 600.03 (28r) , Stats.

(4)   Minimum requirements.

(a) Pursuant to s. 632.84 (2) , Stats., an insurer shall include in any long-term care policy, life insurance-long-term care coverage and any Medicare replacement or supplement policy an internal procedure for benefit appeals.

(b) The insurer shall provide the policyholder and insured with a written description of the benefit appeals internal procedure at the time the insurer gives notice of the denial of a benefit. The written description shall include the name, address, and phone number of the individual designated by the insurer to be responsible for administering the benefit appeals internal procedure.

(c) An insurer shall describe the benefit appeals internal procedure in every policy, group certificate, and outline of coverage. The description shall include a statement on the following:

1. The insured's right to submit a written request in any form, including supporting material, for review by the insurer of the denial of a benefit under the policy; and

2. The insured's right to receive notification of the disposition of the review within 30 days of the insurer's receipt of the benefit appeal.

(d) An insurer shall retain records pertaining to a benefit appeal filed and the disposition of this appeal for at least 3 years from the date that the insurer files with the commissioner under sub. (5) the annual report in which information concerning the appeal is reported.

(e) No insurer may impose a time limit for filing a benefit appeal that is less than 3 years from the date the insurer gives notice of the denial of a benefit.

(f) An insurer shall make any internal procedure established pursuant to s. 632.84 , Stats., available to the commissioner upon request and in as much detail as the commissioner requests.

(5)   Reports to the commissioner. An insurer shall report to the commissioner by March 31 of each year a summary of all benefit appeals filed during the previous calendar year and the disposition of these appeals, including:

(a) The name of the individual designated by the insurer to be responsible for administering the benefit appeals internal procedure;

(b) Changes made in the administration of claims as a result of the review of benefit appeals;

(c) For each benefit appeal, the line of coverage;

(d) The date each benefit appeal was filed and, if within the calendar year, subsequently resolved;

(e) The date each benefit appeal carried over from the previous calendar year was resolved;

(f) The nature of each benefit appeal; and

(g) A summary of each benefit appeal resolution.

(6)   Policy disapproval. The commissioner shall disapprove a policy under s. 631.20 , Stats., if that policy does not meet the minimum requirements specified in this section.

Cr. Register, May, 1989, No. 401 , eff. 1-1-90; am. (1), (2) and (4) (a), r. (3) (f), cr. (3) (cg) and (cm), Register, April, 1991, No. 424 , eff. 6-1-91; EmR0817 : emerg. am. (3) (cg) and (cm), eff. 6-3-08; CR 08-032 : am. (3) (cg) and (cm) Register October 2008 No. 634 , eff. 11-1-08.

Note

CR 08-032 first applies to policies or certificates issued on or after January 1, 2009 or on the first renewal date on or after January 1, 2009, but no later than January 1, 2010 for collectively bargained policies or certificates. Microsoft Windows NT 6.1.7601 Service Pack 1