Delaware Administrative Code
Title 18 - Insurance
1300 - Health Insurance General Provisions
1311 - Standards of Payment for Multiple Surgical Procedures [Formerly Regulation 82]
Section 1311-6.0 - General Business Practice
Current through Register Vol. 28, No. 3, September 1, 2024
6.1 Within a 36 month period, three instances of a health insurer's failure to pay a claim or bill for services as defined in section 5.0 above and in accordance with Insurance Department regulation governing the timeliness of claims handling, shall give rise to a rebuttable presumption that the insurer is in violation of 18 Del.C. § 2304(16)(f).
6.2 The 36 month period established in section 6.1 above shall be measured based upon the date the complaints are received at the Department. Each claim or bill, or portion of a claim or bill, pertaining to a single medical treatment or procedure provided to an individual policyholder that is processed in violation of this regulation shall constitute an "instance" as described in section 6.1 above.
