Internal Appeal Process
What is an Internal Appeal Process?
In accordance with New Jersey law (NJSA 17:29E-9), every insurer writing property and casualty or life insurance (note: health insurance is not listed in the law since these policies provide separate appeal rights) are required to have an internal appeals procedure in place for the review of disputed claims in accordance with rules and regulations promulgated by the Commissioner. The Commissioner adopted rules (NJAC 11:25 -1 et seq) outlining standards and procedures carriers must have in place.
How does the Internal Appeal Process work?
All insurers must provide policyholders and claimants with a written explanation of the insurerís appeal process at some point during the claims process. The communication must describe in non-technical terms how internal appeals are processed and resolved and to whom a request for an appeal may be filed. The review must be conducted by a panel of at least three of the insurance companyís employees, who are not responsible for claims payment on a day to day basis to allow for an objective review of how the claims unit processed the claim. Internal appeals are conducted within 10 business days from receipt of the claimantís written request.
The insurer must also have procedures in place for follow-up action, including methods to inform the claimant of the decision of the Internal Appeals Panel and their right to contact the Office of the Insurance Ombudsman if further review is requested.
Do I have to fill out another form to request the Ombudsmanís review of an Internal Appeal?
No, the Ombudsmanís Office simply requires a request in writing; there are no formal appeal forms to complete. You should, however, submit a copy of the insurance companyís written documentation, including the denial letter and Internal Appeal Panelís findings, as well as any pertinent documentation that may support your position as to why you believe the claim was not settled properly.
Where do I write to request a review of an internal appeal or otherwise file a formal complaint?
You may write to us at:
The Office of the Insurance Ombudsman
NJ Department of Banking and Insurance
PO BOX 472
Trenton, NJ 08625-0472
Phone: (609) 292-5360
Fax: (609) 292-2431