By: Oregon Insurance Division July 10, 2012 --
Oregonians who have long-term care insurance now have the right to have their claims paid promptly and to appeal an insurance company decision to deny benefits.
The changes are due to a 2011 law that became effective for people who buy new policies starting July 1, 2012. For those with existing policies, the law is effective when their policy renews, meaning it will be phased in over a year’s period.
“Consumers with long-term care insurance policies have not had the same protections as consumers with other health insurance claims, yet they are some of the most vulnerable Oregonians,” Oregon Insurance Commissioner Lou Savage said.
“Now, people with long-term care insurance or their representatives can more easily challenge claim denials or delays, which are the most typical complaints we receive,” Savage added.
Long-term care insurance covers people who are chronically ill in a variety of settings – at home, in assisted living, or in a nursing home, for example. Typically, people become eligible for benefits if they can no longer perform certain daily activities such as eating, dressing, or bathing or if they have a mental impairment such as dementia.
Highlights of the law
- Insurers must pay claims that are submitted with all the required information within 30 days of receiving the claim. If they fail to pay on time, they must pay the claim plus interest.
- Consumers may appeal insurers’ decisions that they are ineligible for benefits. If an internal review by the company upholds the denial, consumers may request an external review. In this case, an independent review organization determines if the insurer made the correct decision. The insurer pays the costs of the independent review.
- Insurers who deny a claim for benefits must notify consumers of their appeal rights and the deadlines.
Rules establishing long-term care insurance appeals procedures and the requirement that insurers pay claims promptly can be found here: http://insurance.oregon.gov/rules/attachments/recently%20proposed/id03-2012_rule.pdf.