20:06:47:06. Appeal of adverse
benefit determination. Any plan providing disability benefits, upon receipt
of an appeal of an adverse benefit determination, shall notify a covered person
or, if applicable, the covered person's authorized representative, of the
benefit determination within a reasonable time period, but not later than 45
days after receipt of the request, without regard to whether all the
information necessary to make a benefit determination accompanies the filing.
This time period for making a determination and notifying the covered person of
the covered person's authorized representative may be extended for up to 45
days when necessary due to matters beyond the control of the plan. If the plan
is unable to render a determination within the 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:
special circumstances requiring an extension of time; and
date by which the plan expects to render a determination.
time period for extensions due to the covered person's failure to submit
information necessary to decide a claim shall be tolled from the date on which
the notification of the extension is sent 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.