“Acceptable legitimate disputes” warranting investigations and delays include efforts to get the information necessary to determine whether a claim is medically necessary, efforts to determine whether the services on a claim are “consistent with emergency treatment,” and efforts to investigate accident or cases of suspected fraud, officials write in Connecticut Bulletin HC-69.
When, for example, an insurer is seeking medical information, the “investigations should be limited to issues having a direct relationship to the alleged pre-existing claim or condition which is the subject of the claim,” officials write in the bulletin. “Any investigation done that is not consistent with the terms of HC-66 may be considered to be post claim underwriting.”