11 N.C. Admin. Code 4.0319

Current through Register Vol. 39, No. 12, December 1, 2024

Section 04 .0319 - CLAIMS PRACTICES: LIFE: ACCIDENT AND HEALTH INSURANCE

The Commissioner shall consider as prima facie violative of G.S. 58-63-15(11) the failure by an insurer to adhere to the following procedures concerning settlement of life, accident, health and claims:

(1) Examining Physician's Opinion. When the patient's health is in question, an insurer shall give greater weight to the opinion of a physician who has examined the patient than to the opinion of a physician who has not examined the patient and whose opinion is based solely on a review of the examining physician's notes or reports. As used in this Item, "examination of the patient" shall include the interpretation by a specialist of the results of diagnostic tests performed on the patient by others.

(2) Settlement Offers. Initial offers of settlement or compromise made by an insurer or its representative shall remain open for a period of time of not less than 30 calendar days.

(3) Multiple Health Impairments. When an insured is confined to the hospital with multiple health impairments some of which are excluded from coverage, the insurer or its representative shall make pro rata payments where treatment for excluded conditions can be separated.

(4) Assignment of Benefits. If an accident, health, or disability contract does not prohibit assignment of benefits and an assignment including notice to the insurer prior to the payment of the claim, is made, the insurer shall honor the assignment, even though it may have erroneously paid the insured. Submission of a completed claims form indicating that an assignment is on file shall be treated as though it were submission of the actual assignment.

(5) Claim Status Reports. Health insurance claims subject to 58-3-225 shall be processed in accordance with the provisions of that statute. Otherwise, if benefits claimed under an accident, health, or disability contract have not been paid within 45 days after receipt of the initial claim by the insurer, the insurer shall at that time mail a claim status report to the insured.

11 N.C. Admin. Code 04 .0319

Authority G.S. 58-2-40; 58-3-225; 58-63-15; 58-63-65; 58-65-1; 58-65-40; 58-65-125; 58-67-65; 58-67-150;
Eff. December 15, 1979;
Amended Eff. July 1, 2012; April 8, 2002; April 1, 1989;
Readopted Eff. December 1, 2021.

Authority G.S. 58-2-40; 58-3-225; 58-63-15; 58-63-65; 58-65-1; 58-65-40; 58-65-125; 58-67-65; 58-67-150;
Eff. December 15, 1979;
Amended Eff. July 1, 2012; April 8, 2002; April 1, 1989.

Readopted by North Carolina Register Volume 36, Issue 13, January 3, 2022 effective 12/1/2021.