Utah Admin. Code R590-192-9 - Additional Standards for Prompt, Fair, and Equitable Benefit Determination and Settlement for Income Replacement Insurance

(1) An insurer shall notify a claimant of an adverse benefit determination of an income replacement insurance benefit within 45 days of receipt of a claim.

(a)

(i) If an insurer is unable to make a decision within 45 days due to circumstances beyond the insurer's control, the insurer may extend the time up to 30 additional days.

(ii) If an insurer chooses to extend up to 30 days, the insurer shall notify the claimant before the expiration of the original 45 days.

(iii) The notification shall include:

(A) the circumstances requiring the extension; and

(B) the date by which the insurer expects to render a decision.

(b)

(i) If an insurer cannot render a decision within the first 30-day extension due to circumstances beyond the insurer's control, the insurer may extend the time up to 30 additional days.

(ii) If an insurer chooses to extend up to 30 days, the insurer shall notify the claimant before the expiration of the first 30-day extension.

(iii) The notification shall include:

(A) the circumstances requiring the extension; and

(B) the date by which the insurer expects to render a decision.

(c) Each notice of extension shall explain:

(i) the basis for the extension;

(ii) each unresolved issue that prevents a decision on the claim;

(iii) the information needed to resolve each unresolved issue; and

(iv) that the claimant is given at least 45 days to provide the information.

Notes

Utah Admin. Code R590-192-9

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