PARRIS N. GLENDENING, Governor

Ch. 35

ON WRITTEN REQUEST OF THE CLAIMANT, AN INSURER THAT DENIES A CLAIM
MADE ON AN INDIVIDUAL HEALTH INSURANCE POLICY SHALL GIVE WRITTEN
NOTICE TO THE CLAIMANT THAT STATES FULLY THE REASON FOR THE DENIAL.

(B) EFFECT OF STATED REASON.

THE REASON GIVEN BY AN INSURER FOR DENIAL OF A CLAIM SHALL NOT ACT
AS AN ESTOPPEL OR LIMIT THE INSURER FROM OFFERING AN ADDITIONAL REASON
FOR THE DENIAL.

REVISOR'S NOTE: This section is new language derived without substantive
change from former Art. 48A, § 468A.

In subsection (a) of this section, the reference to a claim "made on an
individual health insurance policy" is substituted for the former reference to a
claim "upon a policy of insurance as provided for in this subtitle" for clarity.

Also in subsection (a) of this section, the former reference to an insurer
"under the provisions of this subtitle" is deleted as unnecessary in light of the
reference to an insurer "that denies a claim made on an individual health
insurance policy".

Defined terms: "Health insurance" § 1-101
"Insurer" § 1-101
"Policy" § 1-101

15-1007. SUMMARY EXPLANATION OF BENEFITS.

(A) SCOPE OF SECTION.

THIS SECTION APPLIES TO INSURERS AND NONPROFIT HEALTH SERVICE PLANS
THAT PROPOSE TO ISSUE OR DELIVER INDIVIDUAL, GROUP, OR BLANKET HEALTH
INSURANCE POLICIES OR CONTRACTS OR TO ADMINISTER HEALTH BENEFIT
PROGRAMS THAT PROVIDE HOSPITAL, MEDICAL, OR SURGICAL BENEFITS ON AN
EXPENSE-INCURRED BASIS.

(B) REQUIRED.

EACH ENTITY SUBJECT TO THIS SECTION SHALL PROVIDE TO AN INSURED
INDIVIDUAL WHO HAS FILED A CLAIM DESCRIBED IN SUBSECTION (C) OF THIS
SECTION AN ANNUAL SUMMARY EXPLANATION OF BENEFITS THAT COVERS THE
PRECEDING 12-MONTH PERIOD.

(C) CONTENTS.

THE SUMMARY EXPLANATION OF BENEFITS REQUIRED UNDER SUBSECTION
(B) OF THIS SECTION SHALL PROVIDE A SUMMARY OF:

(1) ALL CLAIMS FILED BY HEALTH CARE PROVIDERS FOR SERVICES
RENDERED TO THE INSURED INDIVIDUAL OR COVERED DEPENDENT OF THE
INSURED INDIVIDUAL DURING AN INPATIENT HOSPITALIZATION OR AN
OUTPATIENT SURGICAL PROCEDURE;

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