§ 514g-109

514G.109 Benefit trigger determinations — notice — appeals. 1. Notice. When a long-term care insurer determines that the benefit trigger in an insured’s long-term care insurance policy has not been met, the insurer shall provide a clear,written notice to the insured of all of the following: a. The reason that the insurer determined that the insured’s benefit trigger has not been met. b. The insurer’s internal appeal process provided under the insured’s long-term care insurance policy. c. The insured’s right, after exhaustion of the insurer’s internal appeal process, to have the benefit trigger determination reviewed under the independent review process set forth insection 514G.110. 2. Internal appeal.a. An insured may request an internal appeal of a benefit trigger determination by sending a written request to the insurer, along with any additional supporting information,within sixty days after the insured receives the notice described in subsection 1. The internalappeal shall be considered by an individual or group of individuals designated by the insurer,provided that the individual or individuals making the internal appeal decision shall not bethe same individual or individuals

dered by an individual or group of individuals designated by the insurer,provided that the individual or individuals making the internal appeal decision shall not bethe same individual or individuals who made the initial benefit trigger determination. Allinternal appeals shall be completed and written notice of the internal appeal decision sentto the insured within sixty days of the insurer’s receipt of all necessary information uponwhich a final determination can be made. b. If the determination that the benefit trigger was not met is upheld upon internal appeal, the notice of the appeal decision shall describe additional internal appeal rights that areoffered by the insurer, if any. Nothing in this paragraph shall require an insurer to offerany internal appeal rights other than those described in paragraph 'a'. c. If the determination that the benefit trigger was not met is upheld after the internal appeal process has been exhausted and there is no new information not previously providedto the insurer for consideration, the insurer shall provide the insured with a writtendescription of the insured’s right to request an independent review of the benefit triggerdetermination. 3.

ovidedto the insurer for consideration, the insurer shall provide the insured with a writtendescription of the insured’s right to request an independent review of the benefit triggerdetermination. 3. Receipt of notice. Notices required by this section shall be deemed received within five days after the date of mailing. 2008 Acts, ch 1175, §10, 18Referred to in §514G.110 Sat Dec 23 00:45:46 2023 Iowa Code 2024, Section 514G.109 (16, 0)