A California health insurer denies a claim for a covered service. Which statement BEST describes the insured's CLAIM-APPEAL rights?
Explanation
Under California Insurance Code §10123.13, §10123.147, and the Fair Claims Settlement Practices Regulations (10 CCR §2695 et seq.), a health insurer that denies a claim must provide a written explanation of the basis for denial, cite the policy provisions relied upon, and inform the insured of internal appeal rights. After exhausting the insurer's internal review, the insured may request an Independent Medical Review (IMR) for medical-necessity, investigational/experimental, and certain emergency-care denials. IMRs are administered free of charge by the CDI (for CDI-regulated products) or the DMHC (for Knox-Keene plans), and the insurer is bound by the IMR decision. Option A wrongly denies the regulatory appeal scheme. Option C is wrong; insureds may file directly. Option D fabricates a 24-hour deadline; typical appeal windows are 60 to 180 days or longer.
Law Reference: California Insurance Code §10123.13 and §10123.147 (claim handling / appeals)Practice all 315 questions free — no signup required.
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