What Carriers Must Legally Provide

Required disclosures, estimates, coverage positions, and payments carriers owe under state law and policy duties.

Authority Guides › What Carriers Must Legally Provide

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    Overview

    Insurers must communicate promptly, explain coverage decisions, provide estimates that support payments, and issue undisputed benefits without delay. These obligations stem from state unfair claims practices acts and the implied covenant of good faith.

    Key Rules & Requirements

    • Timely acknowledgment and communication: States impose response windows for inquiries and claim status updates.
    • Written coverage positions: Denials or reservations must cite policy provisions and facts relied on.
    • Estimates and basis for payment: Carriers must provide itemized estimates or calculations supporting any payment or reduction.
    • Undisputed payments: Amounts not in dispute must be paid promptly, even if other items remain under review.
    • Claim file transparency: Some states require sharing engineer or adjuster reports used to decide the claim.
    • Interest/penalties: Late payments can trigger statutory interest and bad-faith exposure.

    Step-by-Step Guidance

    1. Request a written coverage position that cites specific policy language.
    2. Ask for itemized estimates and any reports (engineering, hygienist) used in the decision.
    3. Identify undisputed items and request immediate payment with a deadline.
    4. If the carrier needs more time, require a written reason referencing the state regulation that permits extensions.
    5. Where interest or penalties apply, state the statutory citation in your demand.
    6. Escalate to supervisors or regulators if obligations remain unmet.

    Required Documentation

    • Policy excerpts for coverage parts in dispute.
    • Carrier estimates, scope notes, and payment summaries.
    • Engineer/consultant reports relied upon by the insurer.
    • Correspondence log showing requests and response dates.
    • Invoices/estimates demonstrating undisputed costs awaiting payment.

    Common Insurer Tactics

    • Providing lump-sum payments without line-item support.
    • Withholding reports that influenced the denial or reduction.
    • Delaying payments until all supplements are resolved.
    • Issuing oral coverage positions instead of written letters.

    Red Flags to Watch For

    • Denial letters lacking policy citations or factual bases.
    • Estimates missing key trades or code-required items.
    • No release of engineer findings despite reliance on them.
    • Undisputed amounts acknowledged but unpaid beyond statutory timelines.

    Best Practices for Policyholders

    • Ask for all communications to be in writing and retain copies.
    • Respond with side-by-side comparisons highlighting missing scope or pricing.
    • Separate and demand immediate payment for undisputed items.
    • Quote state statutes on prompt payment and interest when following up.
    • Escalate or file a complaint if required disclosures or payments are withheld.
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