(a) An insurer shall establish and maintain an internal complaint process with two levels of review by which a covered person or the covered person's authorized representative shall be able to file a complaint.
(b) The complaint process shall consist of an initial review to include all of the following:
(1) A review by an initial review committee consisting of one or more employes of the insurer.
(2) The allowance of a written or oral complaint.
(3) The allowance of written data or other information.
(4) A review or investigation of the complaint which shall be completed within thirty (30) days of receipt of the complaint.
(5) A written notification to the covered person regarding the decision of the initial review committee within five (5) business days of the decision. Notice shall include the basis for the decision and the procedure to file a request for a second level review of the decision of the initial review committee.
(c) The complaint process shall include a second level review that includes all of the following:
(1) A review of the decision of the initial review committee by a second level review committee consisting of three or more individuals who did not participate in the initial review. At least one third of the second level review committee shall not be employed by the insurer.
(2) A written notification to the covered person of the right to appear before the second level review committee.
(3) A requirement that the second level review be completed within forty-five (45) days of receipt of a request for such review.
(4) A written notification to the covered person regarding the decision of the second level review committee within five (5) business days of the decision. The notice shall include the basis for the decision and the procedure for appealing the decision to the department.
Credits
1921, May 17, P.L. 682, No. 284, § 2141, added 1998, June 17, P.L. 464, No. 68, § 1, effective Jan. 1, 1999. Amended 2022, Nov. 3, P.L. 2068, No. 146, § 2, effective Jan. 1, 2024.
40 P.S. § 991.2141, PA ST 40 P.S. § 991.2141
Current through Act 10 of the 2024 Regular Session. Some statute sections may be more current, see credits for details.
