W. Va. Code R. § 114-32-30

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-32-30 - Prompt Payment of Clean Claims

30.1. For purposes of this section:

30.1.a. "Claim" means a request for payment of benefits under an in-force policy, regardless of whether the benefit claimed is covered under the policy or any terms or conditions of the policy have been met.

30.1.b. "Clean claim" means a claim that has no defect or impropriety, including any lack of required substantiating documentation, such as satisfactory evidence of expenses incurred, or particular circumstance requiring special treatment that prevents timely payment from being made on the claim.

30.2. Within thirty (30) business days after receipt of a claim for benefits under a long-term care insurance policy or certificate, an insurer shall pay such claim if it is a clean claim, or send a written notice acknowledging the date of receipt of the claim and one of the following:

30.2.a. The insurer is declining to pay all or part of the claim and the specific reason(s) for denial; or

30.2.b. That additional information is necessary to determine if all or any part of the claim is payable and the specific additional information that is necessary.

30.3. Within thirty (30) business days after receipt of all the requested additional information, an insurer shall pay a claim for benefits under a long-term care insurance policy or certificate if it is a clean claim, or send a written notice that the insurer is declining to pay all or part of the claim, and the specific reason or reasons for denial.

30.4. If an insurer fails to comply with subsection 30.2 or 30.3 of this rule, such insurer shall pay interest at the rate of 1% per month on the amount of the claim that should have been paid but that remains unpaid forty-five (45) business days after the receipt of the claim with respect to subsection 30.2 of this rule or all requested additional information with respect to subsection 30.3 of this rule. The interest payable pursuant to this subsection shall be included in any late reimbursement without requiring the person who filed the original claim to make any additional claim for such interest.

30.5. The provisions of this section shall not apply where the insurer has a reasonable basis supported by specific information that such claim was fraudulently submitted.

W. Va. Code R. § 114-32-30