Vermont Statutes Title 8 Sec. 8093
Terms Used In Vermont Statutes Title 8 Sec. 8093
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Certificate: means , as used in this chapter, any certificate issued under a group long-term care insurance policy, which policy has been delivered or issued for delivery in this State. See
- Commissioner: means the Commissioner of Financial Regulation. See
- Contract: A legal written agreement that becomes binding when signed.
- Long-term care insurance: means any insurance policy or rider advertised, marketed, offered, or designed to provide coverage for not less than 12 consecutive months for each covered person on an expense incurred, indemnity, prepaid, or other basis, for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services provided in a setting other than an acute care unit of a hospital. See
§ 8093. Denial of claims; written explanation
(a) If a claim under a long-term care insurance contract is denied, the issuer shall, within 60 days of the date of a written request by the policyholder or certificate holder, or a representative thereof:
(1) provide a written explanation of the reasons for the denial; and
(2) make available all information directly related to the denial.
(b) After completion of all internal appeals, the policyholder or certificate holder may appeal the insurer’s benefit trigger determination to an independent review organization designated by the Commissioner, upon payment of a filing fee of no more than $15.00. The filing fee may be waived or reduced upon a finding by the Commissioner that the financial circumstances of the insured warrant a waiver or reduction. All other costs of the independent review shall be paid by the insurer. (Added 2003, No. 124 (Adj. Sess.), § 2, eff. Jan. 1, 2005; amended 2009, No. 137 (Adj. Sess.), § 28.)