S.D. Admin. R. 20:06:53:73
If a plan or issuer fails to strictly adhere to all the requirements of the internal claims and appeals process with respect to a claim, the claimant is deemed to have exhausted the internal claims and appeals process, regardless of whether the plan or issuer asserts that it substantially complied with these requirements. Upon the failure to strictly adhere to the requirements of the internal claims and appeals process, the claimant may initiate an external review and pursue any available remedies under applicable law, such as judicial review.
The claimant is entitled upon written request to an explanation of the plan's or issuer's basis for asserting that it meets this standard. If the external review or the court rejects the claimant's request for immediate review on the basis that the plan met this standard, the claimant has the right to resubmit and pursue the internal appeal under SDCL 58-17I-7.
S.D. Admin. R. 20:06:53:73
General Authority: SDCL 58-17-87, 58-18-79.
Law Implemented: SDCL 58-17-87, 58-18-79.