Nebraska Administrative Code › Topic - INSURANCE, DEPARTMENT OF › Title 210 - NEBRASKA DEPARTMENT OF INSURANCE › Chapter 61 - UNFAIR LIFE, SICKNESS AND ACCIDENT CLAIMS SETTLEMENT PRACTICES RULE › Section 210-61-008 - Standards for prompt, fair and equitable settlements

Current through June 17, 2024
008.01 When a claim
				is denied, written notice of denial shall be sent to the claimant within
				fifteen (15) days of the determination. No insurer shall deny a claim, or
				portion thereof, on the grounds of a specific policy provision, condition or
				exclusion unless reference to such provision, condition, or exclusion is
				included in the denial. The denial must be given in writing, with reasonable
				and accurate explanation. The claim file of the insurer shall contain
				documentation of the denial as required by Section 004.
008.02 If a claim remains unresolved for
				fifteen (15) days from the date proof of loss is received, the insurer shall
				provide the insured a reasonable written explanation for delay. If the
				investigation remains incomplete, the insurer shall, thirty (30) days from the
				date of initial notification the claim is unresolved and every thirty (30) days
				thereafter, send to the insured a reasonable written explanation setting forth
				the reasons additional time is needed for investigation.
008.03 The insurer shall affirm or deny
				liability on claims within a reasonable time and shall tender payment within
				fifteen (15) days of affirmation of liability, if the amount of the claim is
				determined and not in dispute. In claims where multiple coverages are involved
				or portions of the claim are in dispute, payments to a known payee which are
				not in dispute should be tendered within fifteen (15) days after receipt by the
				insurer of settlement information if such payment would terminate the insurer's
				known liability under that individual coverage or portion of the claim which
				was not in dispute. This is notwithstanding the existence of disputes as to
				other portions of coverage.
008.04
				With each claim payment, the insurer shall provide to the insured an
				Explanation of Benefits that shall include, if applicable, the name of the
				provider or services covered, amount charged, dates of service, and a
				reasonable explanation of the computation of benefits.
008.05 An insurer may not impose a penalty
				upon any insured for noncompliance with insurer requirements for
				pre-certification and/or concurrent review unless such penalty is specifically
				and clearly set forth in the policy.
008.06 No insurer shall deny a claim upon
				information obtained in a telephone conversation or personal interview with any
				source unless the telephone conversation or personal interview is documented in
				the claim file.
008.07 Insurers
				offering cash settlements of first party long-term disability income claims,
				except in cases where there is a bona fide dispute as to the coverage for, or
				amount of, the disability, shall develop a present value calculation of future
				benefits (with probability corrections for mortality and morbidity) utilizing
				contingencies such as mortality, morbidity, and interest rates assumptions,
				etc. appropriate to the risk. A copy of the amount so calculated shall be given
				to and attested to by the insured at settlement time.
008.08 If, after an insurer rejects a claim
				or portion thereof, the claimant objects to such rejection and the rejection is
				maintained, the insurer shall notify the claimant in writing that he or she may
				have the matter reviewed by the Nebraska Department of Insurance, and the
				insurer shall provide the claimant with the Department's address and phone
				number.