An Act To Create Uniform Claims Paying Practices in Long-term Care Insurance Policies
Maine Legislature, Session 126, LD 0891
Committee Amendment CA_A_S147 (Senate)
Amends: 24-A MRSA §2436, 24-A MRSA §50

COMMITTEE AMENDMENT "J{ "to S.P. 312, L.D. 891, Bill, "An Act To Create 
Uniform Claims Paying Practices in Long-term Care Insurance Policies" 
Amend the bill in the emergency preamble in the 4th paragraph in the last line (page 
I, line 8 in L.D.) by striking out the following: "are" and inserting the following: 'is' 
Amend the bill by striking out everything after the enacting clause and before the 
emergency clause and inserting the following: 
'Sec. 1. 24-A MRSA §2436, sub-§6 is enacted to read: 
6. This section does not apply to a claim for payment of benefits under a policy or 
certificate of long-term care insurance delivered or issued for delivery in this State. 
Sec. 2. 24-A MRSA §50U3 is enacted to read: 
§5083. Payment of claims 
1. Notice of claim for benefits; response by insured. Notwithstanding any other 
provision of this Title, upon receipt of a notice of claim for benefits under a policy or 
certificate of long-term care insurance delivered or issued for delivery in this State, an 
insurer, whether actively marketing or renewing long-term care insurance in this State, 
shall provide the insured a writttm statement with sufficient detail to permit the insured to 
understand and respond with the documentation specified in subsection 2. The written 
statement must be provided by the insurer within 10 business days following receipt of 
the notice of claim. For purpose:s of this section, "insured" includes a person designated 
by the insured as the insured's representative. 
2. Documentation. The documentation an insurer may require of an insured for the 
payment of a claim for benefits under a policy or certificate of long-term care insurance 
includes, but is not limited to: 
A. A statement from the insured making the claim for benefits: 
COMMIJ~TEE AMENDMENT 
COMMITTEE AMENDMENT "A" to S.P. 312, L.D. 891 
B. A signed release permitting the insurer to obtain personal health care information 
about the insured pursuant to the federal Health Insurance Portability and 
Accountability Act of 1996; 
C. A statement from the insured's physician, including the appropriate diagnosis and 
a treatment and care plan for the insured; 
D. A statement from the long-term care provider rendering services to the insured, 
including an itemized bill for services, the provider's license number and any daily 
nursing notes; and 
E. A copy of any power of attorney executed by the insured. 
Except for information solely in the possession of the insured, the burden is on the insurer 
to obtain any information other than that described in paragraphs A to E that is 
reasonably necessary to payor continue paying the claim. The insured has a continuing 
obligation to cooperate with the insurer in order for the insurer to obtain needed 
information. 
3. Payment of claim. A claim for payment of benefits under a policy or certificate 
oflong-term care insurance delivered or issued for delivery in this State is payable within 
days after the documentation and information identified in subsection 2 as reasonably 
necessary to pay the claim for benefits have been received by the insurer. Within 30 days 
after receipt of that documentation and information, the insurer shall either pay the claim 
or issue a written notice to the insured declining to pay all or part of the claim and the 
specific reason for denial in accordance with this subsection. 
A. An insurer may not extend the time for payment of a claim beyond 30 days after 
receipt of documentation and information related to a technical issue as designated in 
rules adopted by the bureau. 
B. Except as provided in paragraph A, an insurer may delay payment of a claim and 
request additional documentation and information related to a substantive issue as 
designated in rules adopted by the bureau. 
4. Ongoing claim. Except for information solely in the possession of the insured, if, 
during the course of an ongoing claim for benefits paid on a monthly or recurring basis, 
the insurer identifies the need for additional reasonable documentation to ensure the 
insured remains entitled to benefits under the policy or certificate of long-term care 
insurance, the burden is on the insurer to obtain that information. The insured has a 
continuing obligation to cooperate with the insurer in order for the insurer to obtain 
needed information. 
5. 
Appeals of claims denials. 
An insured who receives a claims denial in 
accordance with this section has the right to internal appeal and, after exhausting an 
insurer's internal appeals process, the right to request an external review. The 
superintendent shall adopt rules to determine the standards for internal appeal and 
external review in a manner consistent with model legislation adopted by the National 
Association of Insurance Commissioners, or its successor organization. The written 
notice to the insured declining to pay all or part of the claim as required by subsection 3 
must include a statement informing the insured of the insured's rights to internal appeal 
COMMITTEE AMENDMENT 
COMMITIEE AMENDMENT 'A" to S.P. 312, L.D. 891 
and external review and a statl~ment of the insured's right to seek assistance or file a 
complaint with the bureau and the toll-free telephone number of the bureau. 
6. Interest on overdue claim. An undisputed claim that is not paid within 30 days 
is overdue. If an insurer fails to pay an undisputed claim or any undisputed part of the 
claim when due, the amount of the overdue claim or part of the claim bears interest at the 
rate of 1 112% per month after the due date. 
7. 
Attorney's fees. 
Reasonable attorney's fees for advising and representing a 
claimant on an overdue claim or action for an overdue claim must be paid by the insurer 
if overdue benefits are recovered in an action against the insurer or if overdue benefits are 
paid after receipt of notice of the: attorney's representation. 
8. No limitation on action by insured. This section does not prohibit or limit any 
claim or action for a claim that the insured has against the insurer. 
9. Rules. The superintend.ent may adopt or amend rules in order to carry out the 
purposes of this section. Rules adopted pursuant to this section, including amendments to 
existing rules designated as major substantive, are routine technical rules as defined in 
Title 5, chapter 375, subchapter 2-A. 
Sec. 3. Bureau of Insunmce report; rules. By March 1, 2014, the Department 
of Professional and Financial Regulation, Bureau of Insurance shall submit a report to the 
Joint Standing Committee on Insurance and Financial Services on the rules adopted by 
the bureau as required by the Maine Revised Statutes, Title 24-A, section 5083.' 
SUMMARY 
This amendment replaces the substantive prOVISIons of the bill, but retains the 
emergency preamble and emergency clause. The amendment requires a long-term care 
insurer to pay a claim to an insured within 30 days of receipt of all necessary 
documentation identified by the insurer, which extends the time from 14 days as proposed 
in the bill. The amendment also provides that insurers may delay payment of claims and 
request additional information related only to substantive issues, which are required to be 
designated through rules. 
FISCAL ~OTE REQLlRED 
(~e~~tt~c~e~l 
COMMI1"TEE AMENDMENT 
Approved: 05/27/13 7tvac 
LD891 
LR 1024(02) 
An Act To Create Uniform Claims Paying Practices in Long-term Care Insurance Policies 
Fiscal Detail and Notes 
Fiscal Note for Bill as Amended by Committee Amendment '!t..(S-l4.1) 
Committee: Insurance and Financial Services 
Fiscal Note Required: Yes 
Fiscal Note 
Minor cost increase - Other Special Revenue Funds 
Additional costs for the Bureau of Insurance in the Department of Professional and Financial Regulation are expected 
to be minor and can be absorbed within existing budgeted resources. 
LRI024(02) - Fiscal Note - Page 1 of 1