14VAC5-400-100: Claims settlement standards applicable to accident and sickness insurance, life insurance, and annuities

A. A life or annuity insurer shall review any notice of claim or proof of loss submitted against one policy to determine if such notice of claim or proof of loss may fulfill the insured's obligation under any other policy issued by that insurer.

B. For accident and sickness claims, an insurer shall provide to the insured an explanation of benefits describing the coverage for which the claim is paid or denied within 21 calendar days of receipt of proof of loss, unless otherwise specified in the policy. If an insurer needs additional time to make a determination, it shall send a notice giving the reasons more time is needed to the insured within the timeframe in this subsection.

C. An insurer shall make available a summary of prescription drug claims electronically or provide a written summary at the request of the insured. A summary of prescription drugs shall describe the amounts covered under the policy, amounts denied, and amounts payable by the insured and insurer.

D. An insurer shall not arbitrarily or unreasonably deny or delay payment of a claim in which liability has become reasonably clear.