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8 / 17

% Sample in violation

5% (within tolerance limits)

Result: The Company meets this standard.

Standard #2 Investigation of a claim shall be completed within 30 days after notification of a claim unless the investigation cannot reasonably be completed within this time frame. WAC 284-30-370 (See Appendix III)

The Individual Benefits Guide does not discuss this requirement. However, it should be noted that many requirements, such as Attending Physician Statements, are not completed within the 30 day time limit. The Company does not have control over receiving information from outside sources, but we do note that they consistently follow

up on outstanding requirements.

Total Claim Population

220

# Claims in Sample

77

# Claims not completed within 30 days of notice

41

% Sample in violation

53%

Result: The Company meets this standard where possible. The numbers shown above are due to delays by outside sources. The Company does follow up on the outstanding requests at regular intervals.

Standard #3 Acceptance or denial of a claim must be made within 15 working days after receipt of completed proofs of loss. WAC 284-30-380(1) (Appendix IV)

The Individual Benefit Guide does not discuss this requirement. In

reviewing files for this standard, completed proof of loss is defined as receipt of all material requested as part of the adjudication process, such as attending physician statements, financial statements, independent medical examinations, etc. Of the 77 files examined, one (1) file was not complete at the time of examination, therefore was not included in this standard.

Total Claim Population

  • #

    Claims in Sample

    • #

      Claims without final action within 15 days

% Sample in violation

Result: The Company meets this standard.

220 76 1 1.3% (within 5% tolerance)

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