(1) PURPOSE. This section implements and
Stats., for the purpose of establishing minimum requirements for the internal
procedure for benefit appeals that insurers shall provide in long-term care
policies, life insurance-long-term care coverage. This section also facilitates
the review by the commissioner of these policy forms.
(2) SCOPE. This section applies to individual
and group nursing home insurance policies issued or renewed on or after August
1, 1988, and to long-term care policies and life insurance-long-term care
coverage issued or renewed on and after June 1, 1991, except for polices or
coverage exempt under s. Ins 3.455(2) (b). This section does not apply to
health maintenance organizations, limited service health organization or
preferred provider plan, as those are defined in s.
DEFINITIONS. In this
(a) "Benefit appeal" means a request
for further consideration of actions involving the denial of a
(b) "Denial of a benefit"
means any denial of a claim, the application of a limitation or exclusion
provision, and any refusal to continue coverage.
(c) "Internal procedure" means the insurer's
written procedure for handling benefit appeals.
(cg) "Life insurance-long-term care coverage"
has the meaning provided under s. Ins 3.46(3) (j).
(cm) "Long-term care policy" has the meaning
provided under s. Ins 3.46(3) (k).
(a) Pursuant to s.
Stats., an insurer shall include an internal procedure for benefit appeals in
any long-term care policy or life insurance-long-term care coverage.
(b) The insurer shall provide the
policyholder and insured with a written description of the benefit appeals
internal procedure at the time the insurer gives notice of the denial of a
benefit. The written description shall include the name, address, and phone
number of the individual designated by the insurer to be responsible for
administering the benefit appeals internal procedure.
An insurer shall describe the benefit
appeals internal procedure in every policy, group certificate, and outline of
coverage. The description shall include a statement on the following:
1. The insured's right to submit a written
request in any form, including supporting material, for review by the insurer
of the denial of a benefit under the policy; and
2. The insured's right to receive
notification of the disposition of the review within 30 days of the insurer's
receipt of the benefit appeal.
(d) An insurer shall retain records
pertaining to a benefit appeal filed and the disposition of this appeal for at
least 3 years from the date that the insurer files with the commissioner under
sub. (5) the annual report in which information concerning the appeal is
(e) No insurer may impose
a time limit for filing a benefit appeal that is less than 3 years from the
date the insurer gives notice of the denial of a benefit.
(f) An insurer shall make any internal
procedure established pursuant to s.
Stats., available to the commissioner upon request and in as much detail as the
REPORTS TO THE COMMISSIONER. An insurer
offering a long-term care insurance policy or rider shall report to the
commissioner by March 31 of each year a summary of all benefit appeals filed
during the previous calendar year and the disposition of these appeals,
(a) The name of the individual
designated by the insurer to be responsible for administering the benefit
appeals internal procedure;
Changes made in the administration of claims as a result of the review of
(c) For each
benefit appeal, the line of coverage;
(d) The date each benefit appeal was filed
and, if within the calendar year, subsequently resolved;
(e) The date each benefit appeal carried over
from the previous calendar year was resolved;
(f) The nature of each benefit appeal;
(g) A summary of each benefit
POLICY DISAPPROVAL. The commissioner shall disapprove a policy under s.
Stats., if that policy does not meet the minimum requirements specified in this
Wis. Admin. Code Office of the Commissioner of Insurance § Ins 3.55
Cr. Register, May, 1989,
No. 401, eff. 1-1-90; am. (1), (2) and (4) (a), r. (3) (f), cr. (3) (cg) and
(cm), Register, April, 1991, No. 424, eff. 6-1-91; EmR0817: emerg. am. (3) (cg)
and (cm), eff. 6-3-08; CR 08-032: am. (3) (cg) and (cm) Register October 2008
No. 634, eff. 11-1-08.
Amended by, CR
19-036: am. (title), (1), (2), r. (3) (d), (e), am. (4) (a), (5) (intro.)
December 2019 No. 768, eff.
CR 08-032 first applies to policies or certificates issued on
or after January 1, 2009 or on the first renewal date on or after January 1,
2009, but no later than January 1, 2010 for collectively bargained policies or