COMAR 31.10.30 · Chapter 30 Disability Benefit Claims Procedures

Administrative History Effective date: August 2, 2004 (31:15 Md. R. 1186) Regulation .03B amended effective April 15, 2024 (51:7 Md. R. 334) Regulation .04 amended effective April 15, 2024 (51:7 Md. R. 334) Regulation .05 amended effective April 15, 2024 (51:7 Md. R. 334) Authority Insurance Article, §§ 2-109 (a)( 1 ) and 15-1010 , Annotated Code of Maryland

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.01 Scope. This chapter applies to insurers that issue or deliver individual or group health insurance policies in Maryland that include a disability benefit.

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.02 Definitions. A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) "Adverse appeal determination" means a decision made by an insurer on an appeal of an adverse benefit determination to uphold: (a) A denial, reduction, or termination of a disability benefit; (b) A failure to provide or make payment, in whole or in part, for a disability benefit; or (c) Any denial, reduction, termination, or failure to provide or make payment that is based on a determination of a covered individual's eligibility for coverage of a disability benefit. (2) "Adverse benefit determination" means a determination arising from a claim for disability benefits which results in: (a) A denial, reduction, or termination of a disability benefit; (b) A failure to provide or make payment, in whole or in part, for a disability benefit; or (c) Any denial, reduction, termination, or failure to provide or make payment that is based on a determination of a covered individual's eligibility for coverage of a disability benefit. (3) "Authorized representative" means a person, including a health care provider, authorized by the covered individual to act on behalf of the covered individual. (4) "Covered individual" means an individual covered under an insurance policy that provides a disability benefit. (5) Disability benefit. (a) "Disability benefit" means a benefit that is payable based on the disability of a covered individual. (b) "Disability benefit" does not include: (i) Benefits under a long-term care insurance policy; (ii) A benefit that is payable based solely on a dismemberment of a covered individual; (iii) Benefits in a life insurance policy that operate to safeguard the contract from lapse or to provide a special surrender value, special benefit, or annuity in the event of total and permanent disability; or (iv) Benefits in a health insurance policy that operate to safeguard the contract from lapse due to disability.

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.03 Establishment of Claim and Appeal Procedures. A. Each insurer subject to this chapter shall establish procedures for processing disability benefits claims and appeals of adverse benefit determinations in accordance with this chapter. B. The procedures established by an insurer shall: (1) Be in writing; (2) Contain administrative processes and safeguards designed to ensure and to verify that benefit claim determinations are made in accordance with the insurance policy provisions and that, where appropriate, the insurance policy provisions have been applied consistently with respect to similarly situated covered individuals; (3) Allow covered individuals at least 180 days following receipt of a notice of an adverse benefit determination to request an appeal of the adverse benefit determination; (4) Provide covered individuals an opportunity to submit written comments, documents, records, and other information relating to the claim for disability benefits; (5) Provide a covered individual who is appealing or has appealed an adverse benefit determination, upon request and free of charge, reasonable access to, and copies of all documents, records, and other information relevant to the covered individual's claim for disability benefits; (6) Provide for a review that takes into account all comments, documents, records, and other information submitted by the covered individual appealing an adverse benefit determination, without regard to whether the information was submitted or considered in the initial adverse benefit determination; (7) Require that the review on appeal of an adverse benefit determination be conducted by an individual who is neither the individual who made the adverse benefit determination nor a subordinate of the individual who made the adverse benefit determination; (8) Provide that the review on appeal of an adverse benefit determination may not afford deference to the initial adverse benefit determination; (9) Provide for the identification of medical or vocational experts whose advice was obtained on behalf of the insurer in connection with a covered individual's adverse benefit determination, without regard to whether the advice was relied upon in making the adverse benefit determination; (10) Require the individual deciding an appeal of an adverse benefit determination, based in whole or in part on a medical judgment, to consult with a health care professional who: (a) Has appropriate training and experience in the field of medicine involved in the medical judgment; and (b) Is not: (i) The health care professional consulted in connection with the initial adverse benefit determination; or (ii) The subordinate of the health care professional; (11) Ensure that all claims and appeals are adjudicated in a manner designed to ensure the independence and impartiality of the persons involved in making the decision, and, accordingly, decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual, such as a claims adjudicator or medical or vocational expert, may not be made based upon the likelihood that the individual will support the denial of benefits; (12) Provide that, before the insurer issues an adverse appeal determination, the insurer shall provide the claimant, free of charge, with any new or additional evidence considered, relied upon, or generated by the insurer or other person making the benefit determination in connection with the claim, which shall be provided as soon as possible and sufficiently in advance of the date on which the notice of adverse appeal determination is required to be provided to give the covered individual a reasonable opportunity to respond prior to that date; and (13) Provide that, before the insurer can issue an adverse appeal determination based on a new or additional rationale, the insurer shall provide the claimant, free of charge, with the rationale, which shall be provided as soon as possible and sufficiently in advance. C. The claims procedures established by the insurer: (1) May not: (a) Preclude an authorized representative of a covered individual from acting on behalf of the covered individual in filing a benefit claim or an appeal of an adverse benefit determination; (b) Require the payment of a fee or costs as a condition to filing a claim or appealing an adverse benefit determination; (c) Require a covered individual to complete more than two appeals of an adverse benefit determination before filing a complaint with the Commissioner; or (d) Require a covered individual to submit a dispute regarding a claim for disability benefits to binding arbitration; but (2) May include reasonable procedures for determining whether a person has been authorized to act on behalf of a covered individual. D. For purposes of §B(5) of this regulation and Regulation .05F(3) of this chapter , a document, record, or other information shall be considered relevant to a covered individual's claim if the document, record, or other information: (1) Was relied on in making the adverse benefit determination; (2) Was submitted, considered, or generated in the course of making the adverse benefit determination, without regard to whether the document, record, or other information was relied upon in making the adverse benefit determination; (3) Demonstrates compliance with the procedures required by §B(2) of this regulation ; or (4) Constitutes a statement of policy or guidance of the insurer concerning the denied disability benefit without regard to whether the statement was relied upon in making the adverse benefit determination.

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.04 Timing and Content of Notice of Adverse Benefit Determination. A. An insurer shall give written or electronic notice that complies with the standards imposed by 29 CFR §2520.104b-1(c)(1)(i), (iii), and (iv), of an adverse benefit determination to a covered individual within a reasonable period of time, but not later than 45 days after receipt of a claim for disability benefits, unless the 45-day period is extended in accordance with this regulation. B. Subject to §F(2) of this regulation , the period of time within which a benefit determination shall be made begins at the time a claim is received, without regard to whether all the information necessary to make a benefit claim determination accompanies the filing. C. The 45-day time period under §A of this regulation may be extended for up to 30 days if the insurer: (1) Determines that the extension is necessary due to matters beyond the control of the insurer; and (2) Provides the notice required under §E of this regulation to the covered individual before the expiration of the initial 45-day period. D. The first 30-day extension may be extended for an additional 30 days if the insurer: (1) Determines that, due to matters beyond the control of the insurer, a decision cannot be rendered within the first 30-day extension period; and (2) Provides the notice required under §E of this regulation to the covered individual before the expiration of the first 30-day extension period. E. The notice of an extension under §§C and D of this regulation shall be in writing and include: (1) A description of the circumstances requiring the extension of time; (2) The date by which the insurer plans to render a decision; (3) A specific explanation of: (a) The standards on which entitlement to a disability benefit is based; (b) The unresolved issues that prevent a decision on the claim; and (c) The additional information needed to resolve the issues; and (4) A statement that the covered individual shall be given at least 45 days within which to provide the specified information. F. If the period of time within which a benefit determination is required to be made is extended under §C or D of this regulation due to a covered individual's failure to submit information necessary to decide a claim: (1) The covered individual shall be given at least 45 days within which to provide the information; and (2) The period for making the benefit determination is tolled (temporarily suspended) from the date on which the notice of the extension is sent to the covered individual until the date on which the covered individual responds to the request for additional information. G. The notice of an adverse benefit determination shall include: (1) The specific reason or reasons for the adverse benefit determination; (2) A reference to the specific policy provisions on which the adverse benefit determination is based; (3) A description of any additional material or information necessary for the covered individual to perfect the claim and an explanation of why the material or information is necessary; (4) A description of the insurer's appeal procedures and the time limits applicable to the procedures; (5) If an internal rule, guideline, protocol, or similar criterion was relied on in making the adverse benefit determination, either: (a) The specific rule, guideline, protocol, or other similar criterion; or (b) A statement that: (i) An internal rule, guideline, protocol, or other similar criterion was relied on in making the adverse benefit determination; and (ii) A copy of the rule, guideline, protocol, or other similar criterion will be provided on request free of charge to the covered individual; and (6) A discussion of the decision, including an explanation of the basis for disagreeing with or not following: (a) The views presented by the claimant to the plan of health care professionals treating the claimant and vocational professionals who evaluated the claimant; (b) The views of medical or vocational experts whose advice was obtained on behalf of the plan in connection with a claimant’s adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination; and (c) A disability determination regarding the claimant presented by the claimant to the plan made by the Social Security Administration. H. The notification shall be provided in a culturally and linguistically appropriate manner. I. An insurer is considered to provide relevant notices in a culturally and linguistically appropriate manner if: (1) The insurer provides oral language services, such as a telephone customer assistance hotline, that include answering questions in any applicable non-English language and providing assistance with filing claims and appeals in any applicable non-English language; (2) The insurer provides, upon request, a notice in any applicable non-English language; and (3) The insurer includes in the English version of all notices a statement prominently displayed in any applicable non-English language, clearly indicating how to access the language services provided by the insurer. J. With respect to an address in any United States county to which a notice is sent, a non-English language is an applicable non-English language if 10 percent or more of the population residing in the county is literate only in the same non-English language, as determined in guidance published by the U.S. Secretary of Labor

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.05 Timing and Notice of an Appeal Determination. A. An insurer shall give written or electronic notice that complies with the standards imposed by 29 CFR §2520.104b-1(c)(1)(i), (iii), and (iv), of an appeal determination to a covered individual within a reasonable period of time, but not later than 45 days after receipt of an appeal of an adverse benefit determination, unless the 45-day period is extended in accordance with this regulation. B. Subject to §E of this regulation , the period of time within which an appeal determination shall be made begins at the time an appeal is received, without regard to whether all the information necessary to make an appeal determination accompanies the filing. C. The initial 45-day time period under §A of this regulation may be extended for a period not to exceed 45 days if the insurer: (1) Determines that the extension is necessary due to special circumstances; and (2) Provides the notice required under §D of this regulation to the covered individual prior to the expiration of the initial 45-day period. D. The notice of an extension under §C of this regulation shall be in writing and include: (1) A description of the special circumstances requiring the extension of time; and (2) The date by which the insurer plans to render a decision. E. If the period of time within which an appeal determination is required to be made is extended under §C of this regulation due to a covered individual's failure to submit information necessary to decide the appeal, the period for making the appeal determination shall be tolled (temporarily suspended) from the date on which the notice of the extension is sent to the covered individual until the date on which the covered individual responds to the request for additional information. F. The notice of an adverse appeal determination shall include: (1) The specific reason or reasons for the adverse appeal determination; (2) A reference to the specific policy provisions on which the adverse appeal determination is based; (3) A statement that the covered individual is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the covered individual's claim for benefits; and (4) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse appeal determination, either: (a) The specific rule, guideline, protocol, or other similar criterion; or (b) A statement that: (i) An internal rule, guideline, protocol, or other similar criterion was relied on in making the adverse appeal determination; and (ii) A copy of the rule, guideline, protocol, or other similar criterion will be provided on request free of charge to the covered individual; and (5) The address, telephone number, and facsimile number of the Commissioner. G. An insurer shall provide access to, and copies of, documents, records, and other information described in §F(3) and (4) of this regulation.

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