2009 Iowa Code
Title 13 - Commerce
Subtitle 1 - Insurance and Related Regulation
CHAPTER 514G - LONG=TERM CARE INSURANCE ACT
514G.110 - INDEPENDENT REVIEW OF BENEFIT TRIGGER DETERMINATIONS.

        514G.110  INDEPENDENT REVIEW OF BENEFIT TRIGGER
      DETERMINATIONS.
         1.  Request.  An insured may file a written request for
      independent review of a benefit trigger determination with the
      commissioner after the internal appeal process has been exhausted.
      The request shall be filed within sixty days after the insured
      receives written notice of the insurer's internal appeal decision.
         2.  Fee.  A request for independent review shall be
      accompanied by a twenty-five dollar filing fee.  The commissioner may
      waive the filing fee for good cause.  The filing fee shall be
      refunded if the insured prevails in the independent review process.
         3.  Eligibility for review.  The commissioner shall certify
      that the request is eligible for independent review if all of the
      following criteria are satisfied:
         a.  The insured was covered by a long-term care insurance
      policy issued by the insurer at the time the benefit trigger
      determination was made.
         b.  The sole reason for requesting an independent review is to
      review the insurer's determination that the benefit trigger was not
      met.
         c.  The insured has exhausted all internal appeal procedures
      provided under the insured's long-term care insurance policy.
         d.  The written request for independent review was filed by
      the insured within sixty days from the date of receipt of the
      insurer's internal appeal decision.
         4.  Notice of eligibility.  The commissioner shall provide
      written notice regarding eligibility of a request for independent
      review to the insured and the insurer within two business days from
      the date of receipt of the request.
         a.  If the commissioner decides that the request is not
      eligible for independent review, the written notice shall indicate
      the reasons for that decision.
         b.  If the commissioner certifies that the request is eligible
      for independent review, the insurer may appeal that certification by
      filing a written notice of appeal with the commissioner within three
      business days from the date of receipt of the notice of
      certification.  If upon further review, the commissioner upholds the
      certification, the commissioner shall promptly notify the insured and
      the insurer in writing of the reasons for that decision.
         5.  Qualifications of independent review entities.  The
      commissioner shall maintain a list of qualified independent review
      entities that are certified by the commissioner.  Independent review
      entities shall be recertified by the commissioner every two years in
      order to remain on the list.  In order to be certified, an
      independent review entity shall meet all of the following criteria:
         a.  Have on staff, or contract with, a qualified, licensed
      health care professional in an appropriate field for determining an
      insured's functional or cognitive impairment who can conduct an
      independent review.
         (1)  In order to be qualified, a licensed health care professional
      who is a physician shall hold a current certification by a recognized
      American medical specialty board in a specialty appropriate for
      determining an insured's functional or cognitive impairment.
         (2)  In order to be qualified, a licensed health care professional
      who is not a physician shall hold a current certification in the
      specialty in which that person is licensed, by a recognized American
      specialty board in a specialty appropriate for determining an
      insured's functional or cognitive impairment.
         b.  Ensure that any licensed health care professional who
      conducts an independent review has no history of disciplinary actions
      or sanctions, including but not limited to the loss of staff
      privileges or any participation restrictions taken or pending by any
      hospital or state or federal government regulatory agency.
         c.  Ensure that the independent review entity or any of its
      employees, agents, or licensed health care professionals utilized
      does not receive compensation of any type that is dependent on the
      outcome of a review.
         d.  Ensure that the independent review entity or any of its
      employees, agents, or licensed health care professionals utilized are
      not in any manner related to, employed by, or affiliated with the
      insured or with a person who previously provided medical care to the
      insured.
         e.  Ensure that an independent review entity or any of its
      employees, agents, or licensed health care professionals utilized is
      not a subsidiary of, or owned or controlled by, an insurer or by a
      trade association of insurers of which the insurer is a member.
         f.  Have a quality assurance program on file with the
      commissioner that ensures the timeliness and quality of reviews
      performed, the qualifications and independence of the licensed health
      care professionals who perform the reviews, and the confidentiality
      of the review process.
         g.  Have on staff or contract with a licensed health care
      practitioner, as defined in section 514G.103, subsection 3, who is
      qualified to certify that an individual is chronically ill for
      purposes of a qualified long-term care insurance contract.
         6.  Independent review process.  The independent review
      process shall be conducted as follows:
         a.  Within three business days of receiving a notice from the
      commissioner of the certification of a request for independent review
      or receipt of a denial of an insurer's appeal from such a
      certification, the insurer shall do all of the following:
         (1)  Select an independent review entity from the list certified
      by the commissioner and notify the insured in writing of the name,
      address, and telephone number of the independent review entity
      selected.  The independent review entity selected shall utilize a
      licensed health care professional with qualifications appropriate to
      the benefit trigger determination that is under review.
         (2)  Notify the independent review entity that it has been
      selected to conduct an independent review of a benefit trigger
      determination and provide sufficient descriptive information to
      enable the independent review entity to provide licensed health care
      professionals who will be qualified to conduct the review.
         (3)  Provide the commissioner with a copy of the notices sent to
      the insured and to the independent review entity selected.
         b.  Within three business days of receiving a notice from an
      insurer that it has been selected to conduct an independent review,
      the independent review entity shall do one of the following:
         (1)  Accept its selection as the independent review entity,
      designate a qualified licensed health care professional to perform
      the independent review, and provide notice of that designation to the
      insured and the insurer, including a brief description of the health
      care professional's qualifications and the reasons that person is
      qualified to determine whether the insured's benefit trigger has been
      met.  A copy of this notice shall be sent to the commissioner via
      facsimile.  The independent review entity is not required to disclose
      the name of the health care professional selected.
         (2)  Decline its selection as the independent review entity or, if
      the independent review entity does not have a licensed health care
      professional who is qualified to conduct the independent review
      available, request additional time from the commissioner to have a
      qualified licensed health care professional certified, and provide
      notice to the insured, the insurer, and the commissioner.  The
      commissioner shall notify the review entity, the insured, and the
      insurer of how to proceed within three business days of receipt of
      such notice from the independent review entity.
         c.  An insured may object to the independent review entity
      selected by the insurer or to the licensed health care professional
      designated by the independent review entity to conduct the review by
      filing a notice of objection along with reasons for the objection,
      with the commissioner within ten days of receipt of a notice sent by
      the independent review entity pursuant to paragraph "b".  The
      commissioner shall consider the insured's objection and shall notify
      the insured, the insurer, and the independent review entity of its
      decision to sustain or deny the objection within two business days of
      receipt of the objection.
         d.  Within five business days of receiving a notice from the
      independent review entity accepting its selection or within five
      business days of receiving a denial of an objection to the review
      entity selected, whichever is later, the insured may submit any
      information or documentation in support of the insured's claim to
      both the independent review entity and the insurer.
         e.  Within fifteen days of receiving a notice from the
      independent review entity accepting its selection or within three
      business days of receipt of a denial of an objection to the
      independent review entity selected, whichever is later, an insurer
      shall do all of the following:
         (1)  Provide the independent review entity with any information
      submitted to the insurer by the insured in support of the insured's
      internal appeal of the insurer's benefit trigger determination.
         (2)  Provide the independent review entity with any other relevant
      documents used by the insurer in making its benefit trigger
      determination.
         (3)  Provide the insured and the commissioner with confirmation
      that the information required under subparagraphs (1) and (2) has
      been provided to the independent review entity, including the date
      the information was provided.
         f.  The independent review entity shall not commence its
      review until fifteen days after the selection of the independent
      review entity is final including the resolution of any objection made
      pursuant to paragraph "c".  During this time period, the insurer
      may consider any information provided by the insured pursuant to
      paragraph "d" and overturn or affirm the insurer's benefit
      trigger determination based on such information.  If the insurer
      overturns its benefit trigger determination, the independent review
      process shall immediately cease.
         g.  In conducting a review, the independent review entity
      shall consider only the information and documentation provided to the
      independent review entity pursuant to paragraphs "d" and "e".

         h.  The independent review entity shall submit its decision as
      soon as possible, but not later than thirty days from the date the
      independent review entity receives the information required under
      paragraphs "d" and "e", whichever is received later.  The
      decision shall include a description of the basis for the decision
      and the date of the benefit trigger determination to which the
      decision relates.  The independent review entity, for good cause, may
      request an extension of time from the commissioner to file its
      decision.  A copy of the decision shall be mailed to the insured, the
      insurer, and the commissioner.
         i.  All medical records submitted for use by the independent
      review entity shall be maintained as confidential records as required
      by applicable state and federal laws.  The commissioner shall keep
      all information obtained during the independent review process
      confidential pursuant to section 505.8, subsection 8, except that the
      commissioner may share some information obtained as provided under
      section 505.8, subsection 8, and as required by this chapter and
      rules adopted pursuant to this chapter.
         j.  If an insured dies before completion of the independent
      review, the review shall continue to completion if there is potential
      liability of an insurer to the estate of the insured or to a provider
      for rendering qualified long-term care services to the insured.
         7.  Costs.  All reasonable fees and costs of the independent
      review entity incurred in conducting an independent review under this
      section shall be paid by the insurer.
         8.  Immunity.  An independent review entity that conducts a
      review under this section is not liable for damages arising from
      determinations made during the review.  Immunity does not apply to
      any act or omission made by an independent review entity in bad faith
      or that involves gross negligence.
         9.  Effect of independent review decision.
         a.  The review decision by the independent review entity
      conducting the review is binding on the insurer.
         b.  The independent review process set forth in this section
      shall not be considered a contested case under chapter 17A.
         c.  An insured may appeal the review decision by the
      independent review entity conducting the review by filing a petition
      for judicial review in the district court in the county in which the
      insured resides.  The petition for judicial review shall be filed
      within fifteen business days after the issuance of the review
      decision.  The petition shall name the insured as the petitioner and
      the insurer as the respondent.  The petitioner shall not name the
      independent review entity as a party.  The commissioner shall not be
      named as a respondent unless the insured alleges action or inaction
      by the commissioner under the standards articulated under section
      17A.19, subsection 10.  Allegations made against the commissioner
      under section 17A.19, subsection 10, must be stated with
      particularity.  The commissioner may, upon motion, intervene in a
      judicial review proceeding brought pursuant to this paragraph.  The
      findings of fact by the independent review entity conducting the
      review are conclusive and binding on appeal.
         d.  An insurer shall not be subject to any penalties,
      sanctions, or damages for complying in good faith with a review
      decision rendered by an independent review entity pursuant to this
      section.
         e.  Nothing contained in this section or in section 514G.109
      shall be construed to limit the right of an insurer to assert any
      rights an insurer may have under a long-term care insurance policy
      related to:
         (1)  An insured's misrepresentation.
         (2)  Changes in the insured's benefit eligibility.
         (3)  Terms, conditions, and exclusions contained in the policy,
      other than failure to meet the benefit trigger.
         f.  The requirements of this section and section 514G.109 are
      not applicable to a group long-term care insurance policy that is
      governed by the federal Employee Retirement Income Security Act of
      1974, as codified at 29 U.S.C. § 100 et seq.
         g.  The provisions of this section and section 514G.109 are in
      lieu of and supersede any other third-party review requirement
      contained in chapter 514J or in any other provision of law.
         h.  The insured may bring an action in the district court in
      the county in which the insured resides to enforce the review
      decision of the independent review entity conducting the review or
      the decision of the court on appeal.
         10.  Receipt of notice.  Notice required by this section shall
      be deemed received within five days after the date of mailing.  

         2008 Acts, ch 1175, §11, 18
         Referred to in § 514G.103, 514G.109