State RegulationsNC specificDifficulty 3/5
A North Carolina insurer requests additional information to process a health claim, but the insured never supplies it. What must the insurer do, and what happens if the information later arrives?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
Under G.S. 58-3-225(c),(d), if requested information is not received within 90 days the insurer must deny the claim and notify the insured, but if the information is submitted within one year of the denial the insurer must reopen the claim. This balances prompt claim closure against the insured's right to resurrect a claim once the missing evidence surfaces.
Why the other options are wrong
- A) The statute sets a 90-day outside limit after the request; the claim cannot be left open indefinitely.
- C) When the requested information never arrives, the insurer must deny rather than pay; automatic payment after 90 days is not the rule.
- D) The denial is reopenable for one year under G.S. 58-3-225(d); a permanent bar contradicts the statute.
Memory hook
No info in 90 days means deny - but one year keeps the reopen door open.