S.B. 80 Enrolled

ADVERSE BENEFIT DETERMINATION
AMENDMENTS
2003 GENERAL SESSION
STATE OF UTAH
Sponsor: Peter C. Knudson
This act amends the Insurance Code. The act amends the adverse benefit determination
review process for group health plans to include individual or group health plans and
income replacement or disability income policies.
This act affects sections of Utah Code Annotated 1953 as follows:
AMENDS:
31A-22-629, as last amended by Chapter 308, Laws of Utah 2002
Be it enacted by the Legislature of the state of Utah:
Section 1. Section 31A-22-629 is amended to read:
31A-22-629. Adverse benefit determination review process.
(1) As used in this section:
(a) (i) "Adverse benefit determination" means the:
(A) denial of a benefit;
(B) reduction of a benefit;
(C) termination of a benefit; or
(D) failure to provide or make payment, in whole or in part, for a benefit.
(ii) "Adverse benefit determination" includes:
(A) denial, reduction, termination, or failure to provide or make payment that is based
on a determination of an insured's or a beneficiary's eligibility to participate in a plan;
(B) with respect to individual or group health plans, and income replacement or
disability income policies, a denial, reduction, or termination of, or a failure to provide or make
payment, in whole or in part, for, a benefit resulting from the application of a utilization
review; and
(C) failure to cover an item or service for which benefits are otherwise provided
because it is determined to be:

(I) experimental;
(II) investigational; or
(III) not medically necessary or appropriate.
(b) "Independent review" means a process that:
(i) is a voluntary option for the resolution of an adverse benefit determination;
(ii) is conducted at the discretion of the claimant;
(iii) is conducted by an independent review organization designated by the insurer;
(iv) renders an independent and impartial decision on an adverse benefit determination
submitted by an insured; and
(v) may not require the insured to pay a fee for requesting the independent review.
(c) "Insured" is as defined in Section 31A-1-301 and includes a person who is authorized
to act on the insured's behalf.
(d) "Insurer" is as defined in Section 31A-1-301 and includes:
(i) a health maintenance organization; and
(ii) a third-party administrator that offers, sells, manages, or administers a health
insurance policy or health maintenance organization contract that is subject to this title.
(e) "Internal review" means the process an insurer uses to review an insured's adverse
benefit determination before the adverse benefit determination is submitted for independent
review.
(2) This section applies generally to health insurance policies [and], health maintenance
organization contracts [in effect on or after January 1, 2001], and income replacement or
disability income policies.
(3) (a) An insured may submit an adverse benefit determination to the insurer.
(b) The insurer shall conduct an internal review of the insured's adverse benefit
determination.
(4) Before October 1, 2000, the commissioner shall adopt rules that establish minimum
standards for:
(a) internal reviews;

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(b) independent reviews to ensure independence and impartiality;
(c) the types of adverse benefit determinations that may be submitted to an independent
review; and
(d) the timing of the review process, including an expedited review when medically
necessary.
(5) Nothing in this section may be construed as:
(a) expanding, extending, or modifying the terms of a policy or contract with respect to
benefits or coverage;
(b) permitting an insurer to charge an insured for the internal review of an adverse
benefit determination;
(c) restricting the use of arbitration in connection with or subsequent to an independent
review; or
(d) altering the legal rights of any party to seek court or other redress in connection with:
(i) an adverse decision resulting from an independent review, except that if the insurer is
the party seeking legal redress, the insurer shall pay for the reasonable attorneys fees of the
insured related to the action and court costs; or
(ii) an adverse benefit determination or other claim that is not eligible for submission to
independent review.

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