June 30, 2015
On June 17, 2015, Insurance Commissioner Robertson issued Bulletin 216 to clarify provisions of Indiana law and health care reform related to the payment of benefits during the appeals process. Under Indiana law, it is considered an unfair settlement practice for a company to fail to make prompt payment of a claim where liability is reasonably clear. Furthermore, a health insurance payer is forbidden from retaliating against an individual who has exercised their right to an external grievance review.
It has been reported that health insurance payers may be discontinuing coverage of treatment during the appeals process, even when a portion of the treatment plan is undisputed. The Department of Insurance views the undisputed portion of a plan under appeal as a claim in which liability has become reasonably clear, that discontinuing all benefits during the appeals process may be retaliatory and that any undisputed portion must be covered during the appeals process.
Insurers found in violation of Indiana’s Unfair Settlement Practices Act are subject to fines of up to $25,000 per act or violation, or $50,000 if the violation was knowing; and/or suspension or revocation of the company’s certificate of authority.
Although this bulletin is directed at insurers, awareness of it will help employers ensure that insurers are acting in compliance and that their employees are protected.
Bulletin 216 »