Sec. 31.10.30.03. Establishment of Claim and Appeal Procedures

A. Each insurer subject to this chapter shall establish procedures for processing disability benefits claims and appeals of adverse benefit determinations in accordance with this chapter.

B. The procedures established by an insurer shall:

(1) Be in writing;

(2) Contain administrative processes and safeguards designed to ensure and to verify that benefit claim determinations are made in accordance with the insurance policy provisions and that, where appropriate, the insurance policy provisions have been applied consistently with respect to similarly situated covered individuals;

(3) Allow covered individuals at least 180 days following receipt of a notice of an adverse benefit determination to request an appeal of the adverse benefit determination;

(4) Provide covered individuals an opportunity to submit written comments, documents, records, and other information relating to the claim for disability benefits;

(5) Provide a covered individual who is appealing or has appealed an adverse benefit determination, upon request and free of charge, reasonable access to, and copies of all documents, records, and other information relevant to the covered individual's claim for disability benefits;

(6) Provide for a review that takes into account all comments, documents, records, and other information submitted by the covered individual appealing an adverse benefit determination, without regard to whether the information was submitted or considered in the initial adverse benefit determination;

(7) Require that the review on appeal of an adverse benefit determination be conducted by an individual who is neither the individual who made the adverse benefit determination nor a subordinate of the individual who made the adverse benefit determination;

(8) Provide that the review on appeal of an adverse benefit determination may not afford deference to the initial adverse benefit determination;

(9) Provide for the identification of medical or vocational experts whose advice was obtained on behalf of the insurer in connection with a covered individual's adverse benefit determination, without regard to whether the advice was relied upon in making the adverse benefit determination; and

(10) Require the individual deciding an appeal of an adverse benefit determination, based in whole or in part on a medical judgment, to consult with a health care professional who:

(a) Has appropriate training and experience in the field of medicine involved in the medical judgment; and

(b) Is not:

(i) The health care professional consulted in connection with the initial adverse benefit determination; or

(ii) The subordinate of the health care professional.

C. The claims procedures established by the insurer:

(1) May not:

(a) Preclude an authorized representative of a covered individual from acting on behalf of the covered individual in filing a benefit claim or an appeal of an adverse benefit determination;

(b) Require the payment of a fee or costs as a condition to filing a claim or appealing an adverse benefit determination;

(c) Require a covered individual to complete more than two appeals of an adverse benefit determination before filing a complaint with the Commissioner; or

(d) Require a covered individual to submit a dispute regarding a claim for disability benefits to binding arbitration; but

(2) May include reasonable procedures for determining whether a person has been authorized to act on behalf of a covered individual.

D. For purposes of §B(5) of this regulation and Regulation .05F(3) of this chapter, a document, record, or other information shall be considered relevant to a covered individual's claim if the document, record, or other information:

(1) Was relied on in making the adverse benefit determination;

(2) Was submitted, considered, or generated in the course of making the adverse benefit determination, without regard to whether the document, record, or other information was relied upon in making the adverse benefit determination;

(3) Demonstrates compliance with the procedures required by §B(2) of this regulation; or

(4) Constitutes a statement of policy or guidance of the insurer concerning the denied disability benefit without regard to whether the statement was relied upon in making the adverse benefit determination.