Response Timelines

Deadlines for coverage determinations and status updates once the carrier has what it needs to decide.

Authority Guides › Response Timelines

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    Overview

    After receiving necessary proofs, carriers must issue coverage decisions within statutory windows or explain why more time is needed. Written responses must cite policy provisions and facts.

    Key Rules & Requirements

    • Decision deadlines: Often 30–45 days from receipt of proofs or completion of investigation.
    • Ongoing updates: If more time is needed, carriers must provide periodic status letters (commonly every 30 days) explaining the reason.
    • Specificity: Denials must state the policy provisions and facts supporting the decision.
    • Partial decisions: Undisputed parts must be paid even if other portions remain under review.
    • Extensions: Generic delays are insufficient; the carrier must identify what is outstanding.

    Step-by-Step Guidance

    1. Confirm in writing when the carrier has all requested documents to start the response clock.
    2. If no decision by the deadline, send a time-limit demand citing the statute and requesting payment/decision.
    3. Request written explanations for any extension and a target decision date.
    4. Separate and request payment for undisputed items immediately.
    5. Escalate to supervisors or regulators if status letters are vague or absent.

    Required Documentation

    • Proof-of-loss submission and delivery receipt (if applicable).
    • Timeline of when each requested document was delivered.
    • Carrier status letters and any extension notices.
    • Correspondence requesting decisions and citing statutes.

    Common Insurer Tactics

    • Claiming the investigation is ongoing without specifying what is missing.
    • Issuing oral decisions to avoid written obligations.
    • Delaying decisions while waiting on third-party reports without providing timelines.
    • Bundling undisputed and disputed items to delay all payment.

    Red Flags to Watch For

    • No status letter after the initial deadline passes.
    • Extensions that repeat the same generic reason.
    • Denials with no policy citation or reference to submitted evidence.
    • Refusal to confirm what remains outstanding.

    Best Practices for Policyholders

    • Track when the carrier received all documents and restate that date in follow-ups.
    • Use concise, statute-citing emails for time-limit demands.
    • Request partial decisions to unlock undisputed funds.
    • Escalate promptly when updates lapse; include complaint options if needed.
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