Code of Maryland Regulations › Title 31 - MARYLAND INSURANCE ADMINISTRATION › Subtitle 10 - HEALTH INSURANCE-GENERAL › Chapter 31.10.30 - Disability Benefit Claims Procedures › Section 31.10.30.03 - Establishment of Claim and Appeal Procedures

Current through Register Vol. 51, No. 14, July 12, 2024
A. Each insurer subject to this chapter shall establish procedures for processing disability benefits claims and appeals of adverse benefit determinations in accordance with this chapter.
B. The procedures established by an insurer shall:
(1) Be in writing;
(2) Contain administrative processes and safeguards designed to ensure and to verify that benefit claim determinations are made in accordance with the insurance policy provisions and that, where appropriate, the insurance policy provisions have been applied consistently with respect to similarly situated covered individuals;
(3) Allow covered individuals at least 180 days following receipt of a notice of an adverse benefit determination to request an appeal of the adverse benefit determination;
(4) Provide covered individuals an opportunity to submit written comments, documents, records, and other information relating to the claim for disability benefits;
(5) Provide a covered individual who is appealing or has appealed an adverse benefit determination, upon request and free of charge, reasonable access to, and copies of all documents, records, and other information relevant to the covered individual's claim for disability benefits;
(6) Provide for a review that takes into account all comments, documents, records, and other information submitted by the covered individual appealing an adverse benefit determination, without regard to whether the information was submitted or considered in the initial adverse benefit determination;
(7) Require that the review on appeal of an adverse benefit determination be conducted by an individual who is neither the individual who made the adverse benefit determination nor a subordinate of the individual who made the adverse benefit determination;
(8) Provide that the review on appeal of an adverse benefit determination may not afford deference to the initial adverse benefit determination;
(9) Provide for the identification of medical or vocational experts whose advice was obtained on behalf of the insurer in connection with a covered individual's adverse benefit determination, without regard to whether the advice was relied upon in making the adverse benefit determination;
(10) Require the individual deciding an appeal of an adverse benefit determination, based in whole or in part on a medical judgment, to consult with a health care professional who:
(a) Has appropriate training and experience in the field of medicine involved in the medical judgment; and
(b) Is not:
(i) The health care professional consulted in connection with the initial adverse benefit determination; or
(ii) The subordinate of the health care professional;
(11) Ensure that all claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the decision, and, accordingly, decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual, such as a claims adjudicator or medical or vocational expert, may not be made based upon the likelihood that the individual will support the denial of benefits;
(12) Provide that, before the insurer issues an adverse appeal determination, the insurer shall provide the claimant, free of charge, with any new or additional evidence considered, relied upon, or generated by the insurer or other person making the benefit determination in connection with the claim, which shall be provided as soon as possible and sufficiently in advance of the date on which the notice of adverse appeal determination is required to be provided to give the covered individual a reasonable opportunity to respond prior to that date; and
(13) Provide that, before the insurer can issue an adverse appeal determination based on a new or additional rationale, the insurer shall provide the claimant, free of charge, with the rationale, which shall be provided as soon as possible and sufficiently in advance.