It's important to know your rights if you have a long-term care insurance claim denied, and what the process is to appeal the decision. For more information, read the Bureau's Long-Term Care Insurance Claim Denial Appeals Process (PDF) or call the Consumer Health Care Division at 1-800-300-5000 (toll free in Maine) or 207-624-8475.
Two Levels of Internal Appeal
When a long-term care insurance claim is denied, Maine law requires insurance companies to provide two levels of appeal. Both appeals are internal company appeals and may be requested for any reason.
- The first level written appeal request must be made within 120 days of receiving the claim denial.
- The second level written appeal request must be made within 120 days of receiving a decision on the first level appeal.
The appeals process must be exhausted before a claim denial can proceed to independent external review.
Claims Eligible for Independent External Review
The Bureau oversees the independent external review process and contracts with several independent review organizations (IRO) to conduct reviews. When an external review is conducted, the insurance company pay the IRO's charges.
A policy-holder or their representative can request an external review if they have exhausted the insurance company's appeals process and if one of the following applies:
- The claim was denied on the basis that the policyholder did not meet a clinical standard for benefit eligibility, such as the inability to perform certain activities of daily living, or the existence or degree of cognitive impairment;
- The claim was denied on the basis that it is one of several permitted policy exclusions, such as a preexisting condition, alcoholism or drug addiction.
To request an external review, a policyholder or his or her representative must submit a written request to the Bureau within 120 days after the second level appeal decision is made.
The External Review Decision
The IRO is required to complete the external review within 30 days of receiving the review request. In coming to a decision, the reviewer must consider all relevant clinical information and standards, not just the ones the insurer relied upon. The reviewer decision is binding only on the insurance company. If the decision is not in the insured's favor, he or she may take private legal action if they so choose.