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Rule 20:06:47:04 Initial benefit determination.

          20:06:47:04.  Initial benefit determination. Any plan providing disability benefits shall notify a covered person, or if applicable, the covered person's authorized representative, of a benefit determination within a reasonable time period, but not later than 45 days after receipt of the claim. This time period for making a determination and notifying the covered person or their authorized representative may be extended for up to 30 days when necessary due to matters beyond the control of the plan. If the plan is unable to render a determination within 45 days, the plan must notify the covered person in writing, prior to the end of the initial 45-day period of that fact, and include the following:


          (1)  The standards used to determine benefit entitlement;


          (2)  The issues preventing benefit determination;


          (3)  Any additional information or materials needed to complete the determination;


          (4)  The time period, which may not be less than 45 days, that the covered person or the person's authorized representative has to submit additional information;  and


          (5)  The date by which the plan expects to render determination.


          If the plan is unable to render a determination, due to matters beyond its control, the time period may be extended for a second 30-day period, providing the plan notifies the covered person in writing, prior to the end of the initial 30-day extension and includes the notification requirements listed above. The toll of the time periods begins at the time the claim is filed in accordance with plan procedures without regard to whether all the information necessary accompanies the filing. In regard to time period extensions, the time is tolled from the date on which notice of the extension is sent to the covered person until the date on which the covered person responds to the request for additional information.


          Source: 30 SDR 39, effective September 28, 2003; 37 SDR 241, effective July 1, 2011.

          General Authority: SDCL 58-17H-49.

          Law Implemented: SDCL 58-17H-49.


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