Section Ins 1001.02 - Claims Settlement Time Limits(a) A complete decision regarding member payment or coverage or denial shall be made by the insurer within 30 days of receipt of any health insurance claim. In the event of extenuating circumstances, if a complete coverage decision is not made within 30 days, the insurer shall provide a written explanation to the member claimant justifying such delay. This provision shall not apply to provider-submitted claims for reimbursement for services which have been provided to members.(b) Unless otherwise provided by law, every insurer shall establish procedures to commence an investigation of any claim filed by an insured, claimant, or authorized representative of either within 5 working days upon receipt of notice of loss. The procedures established shall anticipate the seasonal changes in the volume of claims. Every insurer shall mail to every insured, claimant, policyholder, or their authorized representative a notification of all items, statements, or forms as well as blank copies of all statements or forms which the insurer reasonably believes will be required in the settlement of the claim.(c) Unless otherwise provided by law, within 10 working days after acknowledgment of the receipt of a notice of a claim from the insured, claimant, or authorized representative of either, the insurer shall advise the insured, claimant, or authorized representative of either in writing of the acceptance or rejection of the claim. If the insurer needs more time to determine whether the claim should be accepted or rejected, the insurer shall so notify the insured, claimant, or authorized representative of either within 10 working days after acknowledgement of the loss and provide the reasons for the delay.(d) The insurer shall within 30 days from the date of the letter setting forth a need for further time and every 30 days thereafter, send to the insured, claimant, or authorized representative of either a letter setting forth the reasons for the delay in the claim settlement, unless the insured, claimant, or authorized representative otherwise agrees.(e) An insurer shall not justify a delay in processing or paying a claim on the grounds of suspected fraud unless the insurer has notified the department and has provided the department with specific reasons to support its suspicions.(f) Whenever the insurer denies a claim on the basis of no coverage or the amount of loss is below the deductible, the insurer shall inform the insured in writing the reason for the denial and include the department's toll-free telephone number.(g) Any letter setting forth the need for further time after the first 30-day period shall contain the following statement: "We will, of course, be available to you to discuss the position we have taken and answer your questions. You may reach us by calling the customer service number located in this notice or the number on the back of your member identification card, if you have one.
If you have been unable to resolve your concern and are a resident of New Hampshire or have a New Hampshire issued policy, you may take this matter up with the New Hampshire insurance department, as it maintains a service division to investigate complaints at 21 South Fruit Street, Suite 14, Concord, NH, 0330l. The New Hampshire insurance department can be reached, toll-free, by dialing 1-800-852-3416."
(h) Unless otherwise provided by law, every insurer shall pay any amount finally agreed upon in settlement of all or part of a claim not later than 5 working days from the date of such agreement or from the date of the performance by the insured, claimant, or authorized representative of either of all conditions set forth by such agreement.(i) An insurer shall not request of a claimant or insured a waiver of insurer obligations under Ins 1000, except to request a waiver of the 30 day delay letter provision of this rule. This waiver shall be in writing and signed by the insured or claimant. The signed waiver shall be retained in the claim file.N.H. Code Admin. R. Ins 1001.02
#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5649, eff 7-1-93; ss by #6999, eff 5-24-99, EXPIRED: 5-24-07
New. #8900, eff 7-1-07
Amended by Volume XXXV Number 45, Filed November 12, 2015, Proposed by #10962, Effective 10/26/2015, Expires 10/26/2025.Amended by Volume XLI Number 10, Filed March 11, 2021, Proposed by #13173, Effective 4/26/2021, Expires 4/26/2031.