(1) The time periods set forth in section 41-5602, Idaho Code, shall not apply to claims that the insurer reasonably believes involve fraud or misrepresentation by the practitioner or facility or the beneficiary or to instances where the insurer has not been provided the information necessary to evaluate the claim after notice has been given requesting additional information by the insurer as required by section 41-5602(5), Idaho Code.
(2)  The time periods set forth in section 41-5602, Idaho Code, shall not apply to claims that the insurer reasonably believes require medical records, including accident reports, for the purpose of investigating whether a claim is valid for subrogation, or the coordination of benefits payable by the insurer with benefits payable by another insurer or payable under federal or state law.

Terms Used In Idaho Code 41-5605

  • Bankruptcy: Refers to statutes and judicial proceedings involving persons or businesses that cannot pay their debts and seek the assistance of the court in getting a fresh start. Under the protection of the bankruptcy court, debtors may discharge their debts, perhaps by paying a portion of each debt. Bankruptcy judges preside over these proceedings.
  • Beneficiary: means a policyholder, subscriber, member, employer or other person who is eligible for benefits under a contract providing hospital, surgical, or medical expense coverage or a managed care organization policy or agreement under which a third party payer agrees to reimburse for covered health care services rendered to beneficiaries in accordance with the benefits contract. See Idaho Code 41-5601
  • Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
  • Contract: A legal written agreement that becomes binding when signed.
  • Fraud: Intentional deception resulting in injury to another.
  • Insurer: means any insurer that sells hospital, medical, long-term care, or vision insurance policies or certificates and managed care organizations. See Idaho Code 41-5601
  • Practitioner or facility: means any physician, hospital or other person or facility licensed or otherwise authorized to furnish health care services. See Idaho Code 41-5601
  • State: when applied to the different parts of the United States, includes the District of Columbia and the territories; and the words "United States" may include the District of Columbia and territories. See Idaho Code 73-114
(3)  An insurer is not required to comply with the time periods set forth in section 41-5602, Idaho Code, if the insurer is in compliance with a contract with the practitioner or facility which specifies different payment requirements. Payments made within the time periods set forth in section 41-5602, Idaho Code, for the purpose of this chapter, shall be deemed to be made in a reasonable and timely manner.
(4)  An insurer is not required to comply with the periods set forth in section 41-5602, Idaho Code, if the fee or premium entitling a beneficiary to insurance benefits has not been paid in full.
(5)  An insurer is not required to comply with the time periods set forth in section 41-5602, Idaho Code, if failure to comply is due to an act of God, bankruptcy, an act of a governmental authority responding to an act of God or emergency or the result of a strike, walkout or other labor dispute, or act of terrorism.