Utah Admin. Code R590-191-7 - Minimum Standards for Prompt, Fair, and Equitable Benefit Determination and Settlement

(1)

(a) A benefit determination time period begins once an insurer receives a claim, regardless of whether all necessary information was filed with the original claim.

(b) If an insurer requires an extension due to a claimant's failure to submit necessary information, the time period for making a decision is tolled from the date the notice is sent to the claimant through:

(i) the date the claimant provides the necessary information; or

(ii) 48 hours after the end of the time period for the claimant to provide the additional information.

(2) Within 15 days of receiving a proof of loss from a claimant, an insurer shall:

(a) provide written acknowledgment of receipt of the proof of loss;

(b) request any necessary additional information from the claimant; and

(c) begin any necessary investigation of the claim, including requesting additional information from other parties having documentation or information relating to the claim.

(3) If no additional information or investigation is necessary under Subsection (2), an insurer shall provide the claim settlement and a written explanation of benefits to the claimant.

(4) Within 15 days of receiving any communication relating to a claim that reasonably suggests that a response is expected, an insurer shall substantively respond to the communication.

(5)

(a) Within 30 days of receiving a proof of loss from a claimant, an insurer shall complete the investigation of the claim.

(b) If the investigation cannot reasonably be completed within 30 days, an insurer shall:

(i) establish, with adequate records, that the investigation could not be completed within 30 days of its receipt of the proof of loss;

(ii) communicate to the claimant, in writing, the reasons for the delay; and

(iii) continue to communicate in writing at least every 30 days until the claim is either settled or denied.

(6) Within 15 days of completing an investigation, an insurer shall:

(a) provide a claim settlement and a written explanation to the claimant; or

(b) provide, in writing, a denial of the claim and an explanation to the claimant of the reason for the denial.

(7) Closing a claim file without settlement is a denial and must be communicated, in writing, to the claimant according to this rule and the policy provisions.

(8) If recalculation or revisitation of a claim is necessary, the insurer shall comply with the initial claim handling process requirements described in this section.

Notes

Utah Admin. Code R590-191-7

Amended by Utah State Bulletin Number 2023-17, effective 8/22/2023