N.J. Admin. Code § 11:25-2.3

Current through Register Vol. 56, No. 7, April 1, 2024

Section 11:25-2.3 - Complaint and internal appeals system-general requirements

(a) Every insurer shall establish and maintain an internal appeals system to provide for the presentation and review of complaints brought by a consumer. All internal appeals procedures shall, at a minimum, include the following components:

1. A system to record and document the status of all internal appeals including whether the appeal is pending or resolved, the type of coverage, type of claim, the specific disposition of the appeal, and the amount of additional benefits paid on resolved internal appeals. The data shall be maintained for a period of three years from the date the internal appeal is closed and shall be made available to the Department upon request;

2. The availability of an insurer's member service representative to assist insureds, when requested, with information pertaining to the insurer's internal appeals system;

3. Establishment of a specified response time which shall be no more than 10 business days from receipt of the appeal for disposition of an internal appeal;

4. A communication sent to the claimant when the appeal is filed which describes in non-technical terms how internal appeals are processed and resolved;

5. Procedures for follow-up action including methods to inform the complainant of the decision of the internal appeals panel within three working days of its decision; and

6. A mechanism for notifying claimants in writing that they may contact the Insurance Claims Ombudsman if there continues to be dissatisfaction with the decision reached by the insurer's internal appeals panel.

N.J. Admin. Code § 11:25-2.3

Amended by R.2007 d.156, effective 5/7/2007.
See: 38 N.J.R. 4166(a), 39 N.J.R. 1737(b).
Deleted (a)1; recodified former (a)2 through (a)7 as new (a)1 through (a)6; and in (a)1, substituted "three" for "five" and "closed" for "filed".
Amended by R.2011 d.166, effective 6/6/2011.
See: 42 N.J.R. 1981(a), 43 N.J.R. 1350(a).
Rewrote (a)1.